Forms & Documents

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 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
	Choice PPO $2,000 with Ortho Plan Highlights
	Choice PPO $2,000 without Ortho Plan Highlights
	Choice Premier $1,000 with Ortho Evidence of Coverage
	Choice Premier $1,000 with Ortho Evidence of Coverage
	Choice Premier $1,000 with Ortho Plan Highlights
	Choice Premier $1,500 with Ortho Evidence of Coverage
	Choice Premier $1,500 with Ortho Evidence of Coverage
	Choice Premier $1,500 with Ortho Plan Highlights
	Choice Premier $2,000 with Ortho Evidence of Coverage
	Choice Premier $2,000 with Ortho Evidence of Coverage
	Choice Premier $2,000 with Ortho Plan Highlights
	PPO Advantage 400 | $1000 Max | $1000 Ortho SOB
	PPO Advantage 400 | $1000 Max | $1500 Ortho SOB
	PPO Advantage 400 | $1000 Max | D&P Max Waiver | $1000 Ortho SOB
	PPO Advantage 400 | $1000 Max | D&P Max Waiver | $1500 Ortho SOB
	PPO Advantage 400 | $1500 Max | $1000 Ortho SOB
	PPO Advantage 400 | $1500 Max | $1500 Ortho SOB
	PPO Advantage 400 | $1500 Max | D&P Max Waiver | $1000 Ortho SOB
	PPO Advantage 400 | $1500 Max | D&P Max Waiver | $1500 Ortho SOB
	PPO Advantage 400 | $2000 Max | $1000 Ortho SOB
	PPO Advantage 400 | $2000 Max | $1500 Ortho SOB
	PPO Advantage 400 | $2000 Max | D&P Max Waiver | $1000 Ortho SOB
	PPO Advantage 400 | $2000 Max | D&P Max Waiver | $1500 Ortho SOB
	PPO Advantage 400 | $2500 Max | $1000 Ortho SOB
	PPO Advantage 400 | $2500 Max | $1500 Ortho SOB
	PPO Advantage 400 | $2500 Max | D&P Max Waiver | $1000 Ortho SOB
	PPO Advantage 400 | $2500 Max | D&P Max Waiver | $1500 Ortho SOB
	PPO Advantage 400 Voluntary | $1000 Max | $1000 Ortho SOB
	PPO Advantage 400 Voluntary | $1000 Max | $1500 Ortho SOB
	PPO Advantage 400 Voluntary | $1500 Max | $1000 Ortho SOB
	PPO Advantage 400 Voluntary | $1500 Max | $1500 Ortho SOB
	PPO Advantage 400 Voluntary | $2000 Max | $1000 Ortho SOB
	PPO Advantage 400 Voluntary | $2000 Max | $1500 Ortho SOB
	PPO Advantage 400 Voluntary | $2500 Max | $1000 Ortho SOB
	PPO Advantage 400 Voluntary | $2500 Max | $1500 Ortho SOB
	PPO Deluxe 300 | $1500 Max | $1500 Child and Adult Ortho SOB
	PPO Deluxe 300 | $1500 Max | $1500 Child and Adult Ortho SOB
	PPO Deluxe 300 | $1500 Max | $1500 Child Ortho SOB
	PPO Deluxe 300 | $1500 Max | $1500 Child Ortho SOB
	PPO Deluxe 300 | $1500 Max | D&P Max Waiver | $1500 Child and Adult Ortho SOB
	PPO Deluxe 300 | $1500 Max | D&P Max Waiver | $1500 Child Ortho SOB
	PPO Deluxe 300 | $2000 Max | $1500 Child and Adult Ortho SOB
	PPO Deluxe 300 | $2000 Max | $1500 Child Ortho SOB
	PPO Deluxe 300 | $2000 Max | D&P Max Waiver | $1500 Child and Adult Ortho SOB
	PPO Deluxe 300 | $2000 Max | D&P Max Waiver | $1500 Child Ortho SOB
	PPO Deluxe 300 | $2500 Max | $1500 Child and Adult Ortho SOB
	PPO Deluxe 300 | $2500 Max | $1500 Child Ortho SOB
	PPO Deluxe 300 | $2500 Max | $1500 Child Ortho SOB
	PPO Deluxe 300 | $2500 Max | D&P Max Waiver | $1500 Child and Adult Ortho SOB
	PPO Deluxe 300 | $2500 Max | D&P Max Waiver | $1500 Child Ortho SOB
	PPO Deluxe 300 | $3000 Max | $1500 Child and Adult Ortho SOB