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Get Ar Delta Dental Request For Appointment Application 2020-2024

Forms: Request for Appointment Form* (page 2) Agent Fee Agreement* (page 7) *Agencies must complete a Request for Appointment form and Agent Fee Agreement for EACH agent that will sell, solicit or negotiate business for Delta Dental of Arkansas. Fair Credit Reporting Act Disclosure & Authorization (page 18) Direct Deposit Agreement (page 21) W-9 (page 22) 2. I f you are certified to sell ACA Dental plans on the Healthcare Exchange, please provide a copy of your Medicare Lea.

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