Report of Possible Fraudulent Activity


Please complete the following information to report possible fraudulent activity to Delta Dental, and we will investigate and determine if fraud has occurred.

Required fields are indicated by an asterisk *
A. *Description
of activity
B.*Name of individual(s) involved, if known



Telephone number*
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C. Other additional information that might be useful in pursuing this matter


Your Name

Email address

Telephone number
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