Delta Dental Plan Options for Massachusetts Students

TOTAL CHOICE PPO PLAN
2024-2025 Policy Year Enrollment Form

This enrollment form is for the TOTAL CHOICE PLAN. If you meant to enroll in the DeltaCare Dental Plan, please click "Enrollment Form" on the left of this page under the DeltaCare section.

If you purchase the plan now, your coverage will be effective September 1, 2024 through August 31, 2025. The enrollment deadline is midnight on August 10, 2024. No exceptions will be made after the deadline.

TO CONTINUE THE ENROLLMENT PROCESS, PLEASE FILL OUT THE REQUIRED FIELDS BELOW:

If you have a social security number you are required to enter it below. If you are an international student and do not have a social security, please use your student ID and add leading zeros if necessary to make it a 9-digit number.