Forms & Documents

Broker Materials

Appointment & Commission

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

Calculators

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

Forms

MetLife eCensus Format - All Coverages

Enrollment Forms

Employee

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

Employer

	AXA Assistance USA, Inc Service Agreement (only if group is enrolling in Supplemental Life Plan)
	CoPower Census (All Carriers)
	CoPower MetLife Conversion Form
	CoPower ONE AppBuilder - New York
	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 Application for Group Insurance
	MetLife DHMO Group Application (only if group is enrolling in DHMO Plan)
	Metlife HIPAA Request Form
	MetLife Specialty Market Submission Form
	MetLife Statement of Health Form
	W-9 Form

In-Force Group Materials

Employee Forms

	Delta Dental HIPAA Authorization
	Delta Dental PPO Claim Form
	Existing Group Enrollment and Change Form
	Existing Group Enrollment and Change Form (Spanish)
	MetLife Accelerated Benefit Option Form (ABO)
	Unum Change Request Form - Voluntary Life
	Unum Life Long Term Disability Claim Form
	Unum Life Short Term Disability Claim Form
	Unum Portability Form
	Unum Waiver of Premium Claim Form
	VSP Out-of-Network Reimbursement Form
	VSP Out-of-Network Reimbursement Form (Spanish)

Employer Administration

	CoPower Contact Sheet
	Unum Life & AD&D Claim Form

Employer Forms

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

Sales Guides & Flyers

Value Add Programs

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

Product Guides

	2024 Delta Dental Small Business Plans CA Brochure
	CoPower ONE Product and Rate Guide 2024 - California
	CoPower ONE Product and Rate Guide 2024 - New York
	CoPower Select Delta Dental Choice Summary of Benefits & Rate Guide

Brochures/Flyers: Broker/Employer

	CoPower ONE Pick One Flyer CA Region 1
	CoPower ONE Pick One Flyer CA Region 2
	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 Portfolio
	CoPower SELECT Landmark Summary of Benefits and Rate Guide
	CoPower SELECT Unum Grp Voluntary Life Flyer
	CoPower SELECT Unum Product and Rate Guide 2024
	CoPower SELECT VSP Product and Rate Guide 2024
	Delta Dental Cost Estimator Flyer
	Delta Dental Dual Coverage Flyer
	Delta Dental PPO - Power of Choice
	Empower Group Flyer
	MetLife Basic Requirements
	MetLife CA LTD Benefit Summary Workbook
	MetLife Disability
	MetLife PDP Plus Network
	MetLife Preferred Dentist Program
	MetLife Vision
	Unum Group LTD Benefit Summary Flyer
	Unum Through CoPower
	VSP Plan Comparison Signature and Choice

Brochures/Flyers: Member

	7 Ways to Make the Most of Your Dental Plan (PPO + Premier)
	Coordinate Two Plans with Dual Coverage
	Cost Estimator
	Delta Dental Coverage While Traveling
	DeltaCare USA 8 Ways to Make the Most of Your Dental Plan
	Employee Assistance Program Flyer
	Get the Facts Straight - Ortho DCU