DeltaVision Forms

April 24, 2025

DeltaVision Forms

Dental/Vision Enrollment Form

Group Application (Dental/Vision)

New Group Summary (Dental/Vision)

Pool Group Application (2-49 enrolees -- Dental/Vision)

Non-Network Claim Form

DeltaVision® is provided by ProTec Insurance Company, a wholly-owned subsidiary of Delta Dental of Illinois, in association with EyeMed Vision Care networks.

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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 all applicable Federal and State civil rights laws. Delta Dental of Illinois does not discriminate, exclude people, or treat them differently on the basis of gender, sex (which includes discrimination on the basis of sex characteristics, including intersex traits; pregnancy or related conditions; sexual orientation; gender identity or expression; and sex stereotypes), race, color, religious creed, national origin, citizenship, age, physical or intellectual disability, protected veteran status, marital status, genetic information, or any other characteristic protected by law.