Agent Commission Agreement

Apply to Sell TPA Services and Dental Plans by Fax or Mail
To apply to sell our TPA services or dental plans, please complete a Marketing and Services Agreement and fax or mail it to us along with a copy of your state insurance license. To review or print a Marketing and Services Agreement click on the link below.

Marketing and Services Agreement - for Dental Plans
Marketing and Services Agreement - for TPA Services

American Dental Professional Services
Attn: Sales Department
9054 North Deerbrook Trail
Milwaukee, WI 53223-2474

Fax: 414-716-0083

Apply to Sell Dental Plans by Email
If you prefer to e-mail your application, please complete the form below. You must fax or mail a copy of your state license and the signature page of the Marketing and Services Agreement.

* indicates required fields.

Title	Mr. Miss Ms. Mrs. Dr.
First Name *
Last Name *
Company
Address 1 *
Address 2
City *
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Zip Code *
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Desired Effective Date *
Name of Contracting Entity (Company Name, Person's Name) *
EIN or SSN *
General Agent (if applicable)
License Number