Forms & Documents

Enrollment Forms

Employer

	AXA Assistance USA, Inc Service Agreement (only if group is enrolling in Supplemental Life Plan)
	CoPower Enrollment Census - New York
	CoPower Enrollment Census (All Carriers) - California
	CoPower ONE Employer Application - California
	CoPower ONE Employer Application - New York
	CoPower ONE Open Enrollment Request Form
	CoPower SELECT Employer Application with Delta Dental, VSP, UNUM, & Landmark
	MetLife Accelerated Benefit Option Form (ABO)
	MetLife Application for Group Insurance
	MetLife Conversion Form
	MetLife Copower Group Administration Form
	MetLife DHMO Group Application (only if group is enrolling in DHMO Plan)
	MetLife eCensus Format - All Coverages
	MetLife New Group Submission Form
	MetLife Statement of Health Form
	W-9 Form

Summary of Benefits (SOB)

Chiro/Acu: Landmark

	Acupuncture Schedule of Benefits $10 20 Plan Highlights
	Acupuncture Schedule of Benefits $10 20 Plan Highlights
	Acupuncture Schedule of Benefits $10 30 Plan Highlights
	Acupuncture Schedule of Benefits $10 30 Plan Highlights
	Acupuncture Schedule of Benefits $15 20 Plan Highlights
	Acupuncture Schedule of Benefits $15 20 Plan Highlights
	Acupuncture Schedule of Benefits $15 30 Plan Highlights
	Acupuncture Schedule of Benefits $15 30 Plan Highlights
	Acupuncture Schedule of Benefits $20 20 Plan Highlights
	Acupuncture Schedule of Benefits $20 20 Plan Highlights
	Acupuncture Schedule of Benefits $20 30 Plan Highlights
	Acupuncture Schedule of Benefits $20 30 Plan Highlights
	Acupunture Schedule of Benefits $35 10 Plan Hightlights
	Acupunture Schedule of Benefits $35 15 Plan Hightlights
	Acupunture Schedule of Benefits $35 20 Plan Hightlights
	Chiropractic Schedule of Benefits $10 20 Plan Highlights
	Chiropractic Schedule of Benefits $10 20 Plan Highlights
	Chiropractic Schedule of Benefits $10 30 Plan Highlights
	Chiropractic Schedule of Benefits $10 30 Plan Highlights
	Chiropractic Schedule of Benefits $15 20 Plan Highlight
	Chiropractic Schedule of Benefits $15 20 Plan Highlights
	Chiropractic Schedule of Benefits $15 30 Plan Highlights
	Chiropractic Schedule of Benefits $15 30 Plan Highlights
	Chiropractic Schedule of Benefits $20 20 Plan Highlight
	Chiropractic Schedule of Benefits $20 20 Plan Highlights
	Chiropractic Schedule of Benefits $20 30 Plan Highlights
	Chiropractic Schedule of Benefits $20 30 Plan Highlights
	Chiropractic Schedule of Benefits $25 10 Plan Highlights
	Chiropractic Schedule of Benefits $25 15 Plan Highlights
	Chiropractic Schedule of Benefits $25 20 Plan Highlights
	Combined Schedule of Benefits $10 20 Plan Highlights
	Combined Schedule of Benefits $10 20 Plan Highlights
	Combined Schedule of Benefits $10 30 Plan Highlights
	Combined Schedule of Benefits $10 30 Plan Highlights
	Combined Schedule of Benefits $15 20 Plan Highlights
	Combined Schedule of Benefits $15 20 Plan Highlights
	Combined Schedule of Benefits $15 30 Plan Highlights
	Combined Schedule of Benefits $15 30 Plan Highlights
	Combined Schedule of Benefits $20 20 Plan Highlights
	Combined Schedule of Benefits $20 20 Plan Highlights
	Combined Schedule of Benefits $20 30 Plan Highlights
	Combined Schedule of Benefits $20 30 Plan Highlights
	Landmark Chiropractic Only Expanded Evidence of Coverage
	Landmark Chiropractic Only Standard Evidence of Coverage
	Landmark Combined Expanded Evidence of Coverage
	Landmark Combined Standard Evidence of Coverage

Dental HMO: Delta Dental

	CoPower ONE DeltaCare Best Plan Highlights w/$100K Life - New York
	CoPower ONE DeltaCare Best Plan Highlights w/$150K Life - New York
	CoPower ONE DeltaCare Best Plan Highlights w/$25K Life - New York
	CoPower ONE DeltaCare Best Plan Highlights w/$35K Life - New York
	CoPower ONE DeltaCare Best Plan Highlights w/$50K Life - New York
	CoPower ONE DeltaCare Better Plan Highlights w/$100K Life - New York
	CoPower ONE DeltaCare Better Plan Highlights w/$150K Life - New York
	CoPower ONE DeltaCare Better Plan Highlights w/$20K Life - New York
	CoPower ONE DeltaCare Better Plan Highlights w/$35K Life - New York
	CoPower ONE DeltaCare Bronze Plan Highlights w/$100K Life
	CoPower ONE DeltaCare Bronze Plan Highlights w/$150K Life
	CoPower ONE DeltaCare Bronze Plan Highlights w/$15K Life
	CoPower ONE DeltaCare Bronze Plan Highlights w/$35K Life
	CoPower ONE DeltaCare Bronze Plan Highlights w/$50K Life
	CoPower ONE DeltaCare Good Plan Highlights w/$100K Life - New York
	CoPower ONE DeltaCare Good Plan Highlights w/$150K Life - New York
	CoPower ONE DeltaCare Good Plan Highlights w/$15K Life - New York
	CoPower ONE DeltaCare Good Plan Highlights w/$35K Life - New York
	CoPower ONE DeltaCare Good Plan Highlights w/$50K Life - New York
	CoPower ONE DeltaCare Platinum Plan Highlights w/$100K Life
	CoPower ONE DeltaCare Platinum Plan Highlights w/$150K Life
	CoPower ONE DeltaCare Platinum Plan Highlights w/$25K Life
	CoPower ONE DeltaCare Platinum Plan Highlights w/$35K Life
	CoPower ONE DeltaCare Platinum Plan Highlights w/$50K Life
	CoPower ONE DeltaCare Silver/Gold Plan Highlights w/$100K Life
	CoPower ONE DeltaCare Silver/Gold Plan Highlights w/$150K Life
	CoPower ONE DeltaCare Silver/Gold Plan Highlights w/$20K Life
	CoPower ONE DeltaCare Silver/Gold Plan Highlights w/$35K Life
	CoPower ONE DeltaCare Silver/Gold Plan Highlights w/$50K Life
	CoPower ONE DeltaCare Voluntary Highlights
	CoPower ONE DeltaCare Voluntary Highlights - New York
	CoPower ONE DeltaCare Voluntary Plan Highlights - New York
	DHMO Advantage 15B SOB
	DHMO Core 17B SOB
	DHMO Deluxe 11A SOB

Dental PPO w/Ortho: Delta Dental

	Choice PPO $1,000 with Ortho Plan Highlights
	Choice PPO $1,000 without Ortho Plan Highlights
	Choice PPO $1,500 with Ortho Plan Highlights