Forms & Documents

Broker Materials

Appointment & Commission

CoPower Producer Agreement

Calculators

	CoPower ONE Cost Comparison Sheet 2021
	CoPower ONE Employee Contribution Worksheet 2021
	CoPower UNUM Voluntary Life Premium Census Calculator 2021
	CoPower Landmark Rate Calculator (Aug 2021 to July 2022)

Forms

	Specialty Market Submission Form
	MetLife eCensus Format - All Coverages
	MetLife_eCensusFormat_All_Coverages.xls
	Broker-Agency Direct Deposit Authorization Form

Enrollment Forms

Employee

	Delta Dental DeltaCare Claim Form
	Declaration of Disability Over-Age Dependent Child Form
	MetLife Beneficiary Designation Form
	UNUM Beneficiary Designation Form
	UNUM Beneficiary Designation Form (Spanish)
	UNUM Employee Voluntary Life Application
	UNUM Member Voluntary Life Application (Spanish)
	UNUM Evidence of Insurability Form
	UNUM Evidence of Insurability Form (Spanish)
	CoPower SUITE MetLife Beneficiary Designation Form
	CoPower MetLife Dental-Life Disabled Dependent Form
	New Group Enrollment/Waiver Form
	Benefit Waiver and Declination Form
	Delta Dental HIPAA Authorization

Employer

	CoPower MetLife Conversion Form
	CoPower ONE Employer Application
	W-9 Form
	CoPower SELECT Employer Application with VSP
	Application for Group Insurance
	Metlife HIPAA Request Form
	DHMO Group Application (only if group is enrolling in DHMO Plan)
	AXA Assistance USA, Inc Service Agreement (only if group is enrolling in Supplemental Life Plan)
	MetLife Statement of Health Form
	2021 CoPower SELECT Employer Application with Delta, VSP, Unum and Landmark
	CoPower Census (All Carriers)
	CoPower ONE Open Enrollment Request Form

In-Force Group Materials

Employee Administration

	MetLife Accelerated Benefit Option Form (ABO)
	Unum Portability Brochure.pdf

Employee Forms

	Delta Dental PPO Claim Form
	UNUM Portability Form
	UNUM Change Request Form - Voluntary Life
	UNUM Life Long Term Disability Claim Form
	UNUM Life Short Term Disability Claim Form
	VSP Out-of-Network Reimbursement Form
	Unum Portability Brochure (Spanish).pdf
	UNUM Waiver of Premium Claim Form

Employer Administration

	UNUM Life & AD&D Claim Form
	CoPower Contact Sheet
	Group Address Change Form
	Renewal Date Change Request Form
	Group Cancellation Form
	One Time Bank Draft Authorization Form
	Federal COBRA and CalCOBRA Status Notification Form

Employer Forms

	Existing Group Enrollment and Change Form
	Employee Termination Form
	UNUM Notification of Conversion Form
	VSP Affiliate Census (Use only for existing VSP groups adding the Affiliate program)
	Existing Group Enrollment and Change Form (SPANISH)
	Direct Debit Authorization Form

Sales Guides & Flyers

Value Add Programs

	CoPower Vantage Powerful Perks Flyer.pdf
	HR360 CoPower Flyer 2021
	Discount RX Card
	Discount RX Card - Spanish

Product Guides

	2021 Delta Dental Small Business Program Brochure
	CoPower Select Delta Dental Choice Summary of Benefits & Rate Guide 2021
	2022 Delta Dental Small Business Plans CA Brochure

Brochures/Flyers: Broker/Employer

	Cost Comparison for VSP Choice B $20_$20 Flyer.pdf
	Cost Comparison for VSP Choice C $25 Flyer.pdf
	Unum Through CoPower.pdf
	VSP AutoPay Flyer.pdf
	VSP Choice Plan Preferred Provider Affiliate Flyer.pdf
	VSP Win-Win Solutions 2020.pdf
	VSP_Eyeconic_Flyer_2018.pdf
	Unum LTD Healthcare Protect Flyer.pdf
	CPS004 Unum Through CoPower 2020.pdf
	Delta Dental Cost Estimator Flyer.pdf
	Delta Dental PPO - Power of Choice.pdf
	CoPower ONE Advantages Flyer.pdf
	CoPower Pick ONE Flyer - Region 1 2020
	CoPower Pick ONE Flyer - Region 2 2020.pdf
	Life Is Hard. Ancillary Doesn_t Have to Be Flyer.pdf
	The CoPower Portfolio 2021.pdf
	VSP Eyeconic Brochure 2019.pdf
	VSP Eyeconic Talking Points 2019.pdf
	VSP Plan Comparison Signature vs Choice 2019.pdf
	Delta Dental Dual Coverage Flyer.pdf
	CoPower SELECT Unum Grp Voluntary Life Flyer.pdf
	CoPower Pick ONE Flyer 2020
	CoPower ONE DeltaCare Flyer 2020
	CoPower VSP Value Plans Flyer 2020
	CoPower Unum LTD Flyer 2020
	Empower Group Flyer
	CoPower One Snapshot Flyer 2021

Brochures/Flyers: Member

	Worldwide Travel Assistance Employee Wallet Card.pdf
	Worldwide Travel Assistance Flyer.pdf
	Employee Assistance Program Flyer.pdf
	Unum Voluntary Term Life and AD_D Insurance.pdf
	What Would Your Family Do Without Your Income.pdf
	Why Unum Life Insurance Fact Sheet.pdf
	Work-Life Balance EAP Employee Flyer.pdf
	Worldwide Travel Assistance Employee Education Flyer.pdf