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 March 1, 2025 through February 28, 2026. The enrollment deadline is midnight on February 10, 2025. This is the final enrollment period for the 2024-2025 policy year. 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.