CoPower Forms and Applications

Commonly used forms:

CoPower Administration

• Employer Application for Dental & Vision
• Employee Termination Form
       (for terminations from dental, vision or life products through CoPower)
• Direct Debit Authorization Form
• Group Address Change Form
• Group Cancellation Form

Delta Dental

• Dental Enrollment/Change Form
       (for adding new members or making changes to the coverage on any of      CoPower’s Delta Dental or DeltaCare policies)
• Dental Enrollment/Change Form (Spanish)
• Delta Dental and VSP Enrollment/List Form
• Delta Dental Enrollment/List Form

VSP

• VSP Individual Application
• VSP Enrollment/Change Form
       (for additions/changes to CoPower’s VSP policies)
• VSP Enrollment/Change Form (Spanish)
• VSP Application Census
       (for new group submission only)
• Delta Dental and VSP Enrollment/List Form
• VSP Waiver Form

Transamerica

• CoPower Basic Term Life Enrollment Form
• CoPower Basic Term Life Simplified Issue Employee Application ($50,000+)

BeneFLEX COBRA

• BeneFLEX Intent to Enroll Form