Dental Enrollment

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AFSCME Retiree Dental Insurance Enrollment Form

Your dental insurance through Delta Dental is only available to Chapter 13 Retiree members. You can pay online via bank draft or credit card, same way you did your dental insurance, or you can mail in a check for $24/year. Please note: $24/year does not count towards your Delta Dental Insurance. That is a separate cost and must be paid separately. Please see below.

Your Delta Dental Insurance is active January 1, 2025 through December 31, 2025 and is paid yearly. Please note that the open enrollment period for Delta Dental is October 1st through December 1st. This plan goes into effect on January 1, 2025. If you have any questions about Delta Dental Insurance, please call their Customer Service line at 1-800-932-0783 and give the representative the Group Number 21468 or visit www.deltadentalins.com.

Retiree Member #1:
Retiree Member #2:
Family Members:
Please list full names, birthdates and genders for all additional members to be enrolled.

(This information is available at www.deltadentalins.com)

I certify that this enrollment information is true and correct.
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