• Dashboard
  • Edit Page

Menu

Close Navigation
  • Large Group
    • Dental Plans
    • Vision Plans
    • Hearing Health Discount Program
    • What's Needed to Quote
  • Small Group
    • Dental Plans
    • Vision Plans
    • Hearing Health Discount Program
    • Benefits Guide
    • What's Needed to Quote
  • Find a Provider
    • Dentist Provider Search
    • Vision Provider Search
  • Your Health
  • About Us
    • About DDIL
    • Our Foundation
    • Social Impact
    • Careers
    • Contact Us
  • Resources
    • Administrative Guide
    • DeltaVision®
    • Dental Plan Features
    • Group Forms
    • Member Forms
  • Contact Us
  • Sign in
  • Search

I am a ...

Close
  • Individuals & Members
  • Employers & Groups
  • Brokers
  • Dentists
  • Individuals & Members
  • Employers & Groups
  • Brokers
  • Dentists
  • I am a
  • Select State
  • Contact Us
  • Sign in
Delta Dental of Illinois
 MENU
  • Large Group
    • Dental Plans
    • Vision Plans
    • Hearing Health Discount Program
    • What's Needed to Quote
  • Small Group
    • Dental Plans
    • Vision Plans
    • Hearing Health Discount Program
    • Benefits Guide
    • What's Needed to Quote
  • Find a Provider
    • Dentist Provider Search
    • Vision Provider Search
  • Your Health
  • About Us
    • About DDIL
    • Our Foundation
    • Social Impact
    • Careers
    • Contact Us
  • Resources
    • Administrative Guide
    • DeltaVision®
    • Dental Plan Features
    • Group Forms
    • Member Forms
  • Search

Search
Employers & Groups / Resources / Group Forms

Group Forms

Note: You may need to download the form with Adobe or another PDF reader if you'd like to fill in the form electronically on a computer or other digital device.

Large Groups (more than 150 eligible employees)

Group Application with Dental and Vision

Small Groups (2-150 eligible employees)

Small Group Application with Dental and Vision

Enrollment/Change of Status Forms for Group/Employer

  • Enrollment/Change of Status Form for Group/Employer Dental Policy

  • Enrollment/Change of Status Form for Group/Employer Dental Policy (Spanish version)

  • Enrollment/Change of Status Form for Group/Employer Dental Policy (Polish version)

Billing

  • ACH Fully Insured Billing Form

  • ACH Self-Funded Billing Form

Member Forms

Delta Dental of Illinois Member Forms

Employers & Groups

  • Large Group
    • Dental Plans
    • Vision Plans
    • Hearing Health Discount Program
    • What's Needed to Quote
  • Small Group
    • Dental Plans
    • Vision Plans
    • Hearing Health Discount Program
    • Benefits Guide
    • What's Needed to Quote
  • Resources
    • Administrative Guide
    • DeltaVision®
    • Dental Plan Features
    • Group Forms
    • Member Forms

Delta Dental of Illinois' Employer Connection

Get Started

Company Info

  • About Delta Dental of Illinois
  • Contact Us
  • Careers
  • Social Impact
  • Delta Dental of Illinois Foundation
  • DeltaVision

Resources

  • Your Health
  • Blog
  • Member Forms
  • Virtual Dentist Visits
  • Smile Perks
  • Information in Other Languages

Helpful Links

  • Find a Dentist
  • Find a Vision Provider
  • Get a Plan
  • Submit a Claim
  • Appeal a Claim
  • Submit a Grievance
  • Leave Us a Review!

Looking for a different Delta Dental member company?

Copyright © 2023 Delta Dental of Illinois. All Rights Reserved.

  • Facebook
  • Twitter
  • LinkedIn
  • YouTube
  • Instagram

Social Media Disclaimer | Privacy | Terms & Conditions

Delta Dental of Illinois is a part of Delta Dental Plans Association. Through our national network of Delta Dental companies, we offer dental coverage in all 50 states, Puerto Rico and other U.S. territories.

Delta Dental of Illinois complies with applicable Federal civil rights laws and does not discriminate on the basis of sex, sexual orientation, race, color, religious creed, national origin, citizenship, age, physical or mental disability, protected veteran status, gender, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.