Forms & Documents

Broker Materials

Appointment & Commission

	CoPower Producer Agreement NY
	CoPower Producer Agreement CA
	Broker-Agency Direct Deposit Authorization Form

Calculators

	CoPower UNUM Voluntary Life Premium Census Calculator
	CoPower ONE New York Cost Comparison Calculator
	CoPower ONE California Cost Comparison Calculator
	CoPower Landmark Rate Calculator (Nov 2023 to July 2024)
	CoPower Landmark Rate Calculator (Aug 2023 to Oct 2023)
	CoPower UNUM Supplemental Life Premium Census Calculator - New York

Forms

MetLife eCensus Format - All Coverages

Enrollment Forms

Employee

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

Employer

	CoPower Census (All Carriers)
	CoPower Select AppBuilder
	CoPower ONE AppBuilder - California
	CoPower ONE AppBuilder - New York
	CoPower ONE Open Enrollment Request Form
	CoPower MetLife Conversion Form
	CoPower ONE Employer Application
	W-9 Form
	Application for Group Insurance
	Specialty Market Submission Form
	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
	CoPower SELECT Employer Application with Delta Dental, VSP, UNUM, & Landmark (Jan)
	CoPower SELECT Employer Application with Delta Dental, VSP, UNUM, & Landmark (Feb)

In-Force Group Materials

Employee Forms

	UNUM Waiver of Premium Claim Form
	Existing Group Enrollment and Change Form (Spanish)
	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
	Existing Group Enrollment and Change Form
	Delta Dental PPO Claim Form
	MetLife Accelerated Benefit Option Form (ABO)
	VSP Out-of-Network Reimbursement Form (Spanish)

Employer Administration

	CoPower Contact Sheet
	UNUM Life & AD&D Claim Form

Employer Forms

	UNUM Notification of Conversion Form
	VSP Affiliate Census (Use only for existing VSP groups adding the Affiliate program)
	Employee Termination Form
	Federal COBRA and CalCOBRA Status Notification Form
	Group Address Change Form
	Renewal Date Change Request Form
	Group Cancellation Form
	One Time Bank Draft Authorization Form
	Direct Debit Authorization Form

Sales Guides & Flyers

Value Add Programs

	Zywave CoPower Flyer
	CoPower Vantage Powerful Perks Flyer
	Discount RX Card
	Discount RX Card - Spanish

Product Guides

	CoPower Select Delta Dental Choice Summary of Benefits & Rate Guide
	CoPower ONE Summary of Benefits & Rate Guide NY
	2023 Delta Dental Small Business Plans CA Brochure
	CoPower ONE Summary of Benefits & Rate Guide CA
	2024 Delta Dental Small Business Plans CA Brochure

Brochures/Flyers: Broker/Employer

	Empower Group Flyer
	CoPower ONE Snapshot Flyer
	CoPower SELECT Unum Summary of Benefits and Rate Guide
	The CoPower Portfolio
	CoPower SELECT VSP Product & Rate Guide
	CoPower ONE New York Snapshot Flyer
	MetLife CA LTD Benefit Summary Workbook
	CoPower ONE Pick One New York Level 1 Region 1
	CoPower ONE Pick One New York Level 1 Region 2
	CoPower ONE Pick One New York Level 1 Region 3
	CoPower ONE Pick One New York Level 2 Region 1
	CoPower ONE Pick One New York Level 2 Region 2
	CoPower ONE Pick One New York Level 2 Region 3
	CoPower ONE Pick One California Region 1
	CoPower ONE Pick One California Region 2
	VSP Plan Comparison Signature and Choice
	MetLife Basic Requirements
	Delta Dental Cost Estimator Flyer
	Delta Dental PPO - Power of Choice
	CoPower ONE Advantages Flyer
	Unum Through CoPower
	MetLife Preferred Dentist Program
	PDP Plus Network
	MetLife Disability
	MetLife Vision
	CoPower SELECT Landmark Summary of Benefits and Rate Guide
	Delta Dental Dual Coverage Flyer
	CoPower SELECT Unum Grp Voluntary Life Flyer