Forms & Documents

Broker Materials

Appointment & Commission

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

Calculators

	CoPower ONE New York Cost Comparison Calculator
	CoPower UNUM Voluntary Life Premium Census Calculator

Enrollment Forms

Employee

	Benefit Waiver and Declination Form
	Delta Dental DeltaCare Claim Form
	New Group Enrollment/Waiver Form
	New Group Enrollment/Waiver Form (Spanish)
	UNUM Beneficiary Designation Form (Spanish)
	UNUM Employee Voluntary Life Application
	UNUM Evidence of Insurability Form
	UNUM Evidence of Insurability Form (Spanish)
	UNUM Member Voluntary Life Application (Spanish)

Employer

	CoPower Census (All Carriers)
	CoPower ONE Employer Application - California
	CoPower ONE Open Enrollment Request Form
	W-9 Form

In-Force Group Materials

Employee Forms

	Delta Dental HIPAA Authorization
	Delta Dental PPO Claim Form
	UNUM Change Request Form - Voluntary Life
	UNUM Life Long Term Disability Claim Form
	UNUM Life Short Term Disability Claim Form
	UNUM Portability Form
	VSP Out-of-Network Reimbursement Form
	Existing Group Enrollment and Change Form
	Existing Group Enrollment and Change 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

Sales Guides & Flyers

Value Add Programs

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

Product Guides

	CoPower ONE Product and Rate Guide 2024 - New York
	CoPower ONE Product and Rate Guide 2024 - California

Brochures/Flyers: Broker/Employer

	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
	Delta Dental Cost Estimator Flyer
	Delta Dental PPO - Power of Choice
	Empower Group Flyer
	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
	Get the Facts Straight - Ortho DCU
	Make the Most of Your Dental Plan (PPO)
	PPO + Premier Product Flyer
	VSP Eyeconic
	VSP Eyeconic Save Time and Money
	VSP Freedom to Choose with Retail
	VSP Ultimate Provider Playlist with Retail
	Where's My ID Card - Delta PPO or Premier

Summary of Benefits (SOB)

Dental HMO: Delta Dental

CoPower ONE DeltaCare Voluntary Highlights