Enrollment Forms
Employer
Forms
CoPower Enrollment Census - New York
MetLife Copower Group Administration Form
CoPower SELECT Employer Application with Delta Dental, VSP, UNUM, & Landmark
CoPower ONE Employer Application - New York
CoPower ONE Open Enrollment Request Form
CoPower Enrollment Census (All Carriers) - California
MetLife Statement of Health Form
CoPower ONE Employer Application - California
W-9 Form
MetLife Application for Group Insurance
MetLife New Group Submission Form
MetLife eCensus Format - All Coverages
MetLife 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 Conversion Form
MetLife Accelerated Benefit Option Form (ABO)
Employee
Forms
New Group Enrollment/Waiver Form (Spanish)
Benefit Waiver and Declination Form
New Group Enrollment/Waiver Form
Unum Beneficiary Designation Form (Spanish)
Unum Employee Voluntary Life Application
Unum Member Voluntary Life Application (Spanish)
UnumEvidence of Insurability Form
Unum Evidence of Insurability Form (Spanish) 
MetLife Dental-Life Disabled Dependent Form
Delta Dental DeltaCare Claim Form
Declaration of Disability Over-Age Dependent Child Form
MetLife Beneficiary Designation Form 
Unum Beneficiary Designation Form
Sales Guides & Flyers
Product Guides
Forms
CoPower ONE Product and Rate Guide 2025 - California
CoPower Select Delta Dental Choice Summary of Benefits & Rate Guide 2025
2025 Delta Dental Small Business Plans CA Brochure
CoPower SELECT VSP Product and Rate Guide 2025
CoPower SELECT Unum Product and Rate Guide 2025
CoPower SELECT Landmark Product and Rate Guide (January 1 – December 31, 2025)
CoPower ONE Product and Rate Guide 2024 - New York
CoPower SELECT Landmark Product and Rate Guide (November 1 – December 31, 2024)
2024 Delta Dental Small Business Plans CA Brochure
CoPower ONE Product and Rate Guide 2024 - California
CoPower Select Delta Dental Choice Summary of Benefits & Rate Guide 2024
CoPower SELECT Landmark Product and Rate Guide (January 1 – October 31, 2024)
CoPower SELECT Unum Product and Rate Guide 2024
CoPower SELECT VSP Product and Rate Guide 2024
Brochures/Flyers: Broker/Employer
Forms
CoPower & Unum Key Points and Differentiators
Unum Group LTD Benefit Summary Flyer
CoPower ONE Pick One Flyer CA Region 2
CoPower Portfolio
CoPower ONE Pick One Flyer CA Region 1
VSP Plan Comparison Signature and Choice
CoPower ONE Pick One New York Level 2 Region 3
CoPower ONE Pick One New York Level 2 Region 2
CoPower ONE Pick One New York Level 2 Region 1
CoPower ONE Pick One New York Level 1 Region 3
CoPower ONE Pick One New York Level 1 Region 2
CoPower ONE Pick One New York Level 1 Region 1
Empower Group Flyer
CoPower SELECT Unum Grp Voluntary Life Flyer
Delta Dental Dual Coverage Flyer
Delta Dental Cost Estimator Flyer
Delta Dental PPO - Power of Choice
Unum Through CoPower
Brochures/Flyers: Member
Forms
Resources at Your Fingertips - Online Tools
Member Perks for Your Smile and Beyond (Spanish)
Member Perks for Your Smile and Beyond
Get Check-ups Remotely with Virtual Dentistry!
BrushSmart™ transforms your oral health
Where's My ID Card (Spanish)
VSP Put Your Eyes At Ease with VSP LightCare (Member)
VSP Essential Medical Eye Care (Member)
Unum Long Term Disability Benefit Summary Flyer
Unum Why Buy AD&D Insurance Employee Flyer
Unum Why Buy Term Life Insurance Employee Flyer
Unum Group LTD Employee Education Flyer
VSP EasyOptions
VSP Ultimate Provider Playlist with Retail
VSP Freedom to Choose with Retail
VSP Eyeconic Save Time and Money
VSP Eyeconic
PPO + Premier Product Flyer
Make the Most of Your Dental Plan (PPO)
DeltaCare USA 8 Ways to Make the Most of Your Dental Plan
Delta Dental Coverage While Traveling
Cost Estimator
Coordinate Two Plans with Dual Coverage
7 Ways to Make the Most of Your Dental Plan (PPO + Premier)
Group Voluntary Term Life EE Guide
VSP/CoPower Your Vision Coverage Works Overtime
VSP/CoPower - See Well. Be Well.
Where's My ID Card
Get the Facts Straight - Ortho DCU
Unum Voluntary Life Plan Benefit Rate Sheet
Worldwide Travel Assistance Flyer
Employee Assistance Program Flyer
Unum Voluntary Term Life and AD&D Insurance
What Would Your Family Do Without Your Income
Worldwide Travel Assistance Employee Wallet Card
Value Add Programs
Forms
Discount RX Card - Spanish
Zywave CoPower Flyer
Discount RX Card
CoPower Vantage Powerful Perks Flyer
Broker Materials
Calculators
Forms
CoPower UNUM Voluntary Life Premium Census Calculator 2025
CoPower Landmark Rate Calculator (January 2025 to December 2025)
CoPower UNUM Supplemental Life Premium Census Calculator - New York
CoPower Landmark Rate Calculator (Nov 2024 to December 2024)
CoPower ONE New York Cost Comparison Calculator
CoPower UNUM Voluntary Life Premium Census Calculator 2024
Appointment & Commission
Forms
MetLife SBS Commission Agreement and Acknowledgement
CoPower Producer Agreement NY
Broker-Agency Direct Deposit Authorization Form
CoPower Producer Agreement CA
Summary of Benefits (SOB)
LTD: Unum
Forms
Unum LTD Benefit Summary 10-Life+ 360 Day EP
Unum LTD Benefit Summary 10-Life+ 180 Day EP
Unum LTD Benefit Summary 10-Life+ 90 Day EP
Dental HMO: Delta Dental
Forms
CoPower ONE DeltaCare Platinum Plan Highlights w/$150K Life
CoPower ONE DeltaCare Platinum Plan Highlights w/$100K Life
CoPower ONE DeltaCare Platinum Plan Highlights w/$50K Life
CoPower ONE DeltaCare Platinum Plan Highlights w/$35K Life
CoPower ONE DeltaCare Platinum Plan Highlights w/$25K Life
CoPower ONE DeltaCare Silver/Gold Plan Highlights w/$150K Life
CoPower ONE DeltaCare Silver/Gold Plan Highlights w/$100K Life
CoPower ONE DeltaCare Silver/Gold Plan Highlights w/$50K Life
CoPower ONE DeltaCare Silver/Gold Plan Highlights w/$35K Life
CoPower ONE DeltaCare Silver/Gold Plan Highlights w/$20K Life
CoPower ONE DeltaCare Bronze Plan Highlights w/$150K Life
CoPower ONE DeltaCare Bronze Plan Highlights w/$100K Life
CoPower ONE DeltaCare Bronze Plan Highlights w/$50K Life
CoPower ONE DeltaCare Bronze Plan Highlights w/$35K Life
CoPower ONE DeltaCare Bronze Plan Highlights w/$15K Life
CoPower ONE DeltaCare Best Plan Highlights w/$150K Life - New York
CoPower ONE DeltaCare Best Plan Highlights w/$100K Life - New York
CoPower ONE DeltaCare Best Plan Highlights w/$50K Life - New York
CoPower ONE DeltaCare Best Plan Highlights w/$35K Life - New York
CoPower ONE DeltaCare Best Plan Highlights w/$25K Life - New York
CoPower ONE DeltaCare Better Plan Highlights w/$150K Life - New York
CoPower ONE DeltaCare Better Plan Highlights w/$100K Life - New York
CoPower ONE DeltaCare Better Plan Highlights w/$50K Life - New York
CoPower ONE DeltaCare Better Plan Highlights w/$35K Life - New York
CoPower ONE DeltaCare Better Plan Highlights w/$20K Life - New York
CoPower ONE DeltaCare Good Plan Highlights w/$150K Life - New York
CoPower ONE DeltaCare Good Plan Highlights w/$100K Life - New York
CoPower ONE DeltaCare Good Plan Highlights w/$50K Life - New York
CoPower ONE DeltaCare Good Plan Highlights w/$35K Life - New York
CoPower ONE DeltaCare Good Plan Highlights w/$15K Life - New York
CoPower ONE DeltaCare Voluntary Highlights - New York
CoPower ONE DeltaCare Voluntary Plan Highlights - New York
DHMO Core 17B SOB
DHMO Advantage 15B SOB
DHMO Deluxe 11A SOB
CoPower ONE DeltaCare Voluntary Highlights
Dental PPO: Delta Dental
Forms
CoPower ONE Best Plan Highlights w/$150K Life - New York
CoPower ONE Best Plan Highlights w/$100K Life - New York
CoPower ONE Best Plan Highlights w/$50K Life - New York
CoPower ONE Best Plan Highlights w/$35K Life - New York
CoPower ONE Best Plan Highlights w/$25K Life - New York
CoPower ONE Better Plus Plan Highlights w/$150K Life - New York
CoPower ONE Better Plus Plan Highlights w/$100K Life - New York
CoPower ONE Better Plus Plan Highlights w/$50K Life - New York
CoPower ONE Better Plus Plan Highlights w/$35K Life - New York
CoPower ONE Better Plus Plan Highlights w/$20K Life - New York
CoPower ONE Better Plan Highlights w/$150K Life - New York
CoPower ONE Better Plan Highlights w/$100K Life - New York
CoPower ONE Better Plan Highlights w/$50K Life - New York
CoPower ONE Better Plan Highlights w/$35K Life - New York
CoPower ONE Better Plan Highlights w/$20K Life - New York
CoPower ONE Good Plan Highlights w/$150K Life - New York
CoPower ONE Good Plan Highlights w/$100K Life - New York
CoPower ONE Good Plan Highlights w/$50K Life - New York
CoPower ONE Good Plan Highlights w/$35K Life - New York
CoPower ONE Good Plan Highlights w/$15K Life - New York
CoPower ONE Highlights Voluntary Plan
CoPower ONE Benefit Highlights Voluntary Plan No Ortho
CoPower ONE Platinum Plan Highlights w/$150K Life
CoPower ONE Platinum Plan Highlights w/$100K Life
CoPower ONE Platinum Plan Highlights w/$50K Life
CoPower ONE Platinum Plan Highlights w/$35K Life
CoPower ONE Platinum Plan Highlights w/$25K Life
CoPower ONE Gold Plan Highlights w/$150K Life
CoPower ONE Gold Plan Highlights w/$100K Life
CoPower ONE Gold Plan Highlights w/$50K Life
CoPower ONE Gold Plan Highlights w/$35K Life
CoPower ONE Gold Plan Highlights w/$20K Life
CoPower ONE Silver Plan Highlights w/$150K Life
CoPower ONE Silver Plan Highlights w/$100K Life
CoPower ONE Silver Plan Highlights w/$50K Life
CoPower ONE Silver Plan Highlights w/$35K Life
CoPower ONE Silver Plan Highlights w/$20K Life
CoPower ONE Bronze Plan Highlights w/$150K Life
CoPower ONE Bronze Plan Highlights w/$100K Life
CoPower ONE Bronze Plan Highlights w/$50K Life
CoPower ONE Bronze Plan Highlights w/$35K Life
CoPower ONE Bronze Plan Highlights w/$15K Life
CoPower ONE Voluntary Plan Highlights Without Ortho
CoPower ONE Voluntary Plan Highlights MBP No Ortho - New York
CoPower ONE Voluntary Plan Highlights MBP w/Ortho - New York
PPO Plus Premier Dual Choice Buy-up | $2000 Max SOB
PPO Dual Choice Buy-up | $2000 Max SOB
PPO Plus Premier Dual Choice Buy-up | $1500 Max SOB
PPO Dual Choice Buy-up | $1500 Max SOB
PPO Plus Premier Dual Choice Core | $1000 Max SOB
PPO Dual Choice Core | $1000 Max SOB
PPO Plus Premier Dual Choice 3 Voluntary | $2500 Max SOB
PPO Plus Premier Dual Choice 3 Voluntary | $1500 Max SOB
PPO Plus Premier Dual Choice 3 Voluntary | $1000 Max SOB
PPO Plus Premier Dual Choice 3 Low | $1500 Max | $1000 Ortho SOB
PPO Plus Premier Dual Choice 3 Low | $1500 Max SOB
PPO Plus Premier Dual Choice 3 Low | $1000 Max SOB
PPO Plus Premier Dual Choice 3 High | $2500 Max | D&P Max Waiver SOB
PPO Plus Premier Dual Choice 3 High | $2500 Max SOB
PPO Plus Premier Dual Choice 3 High | $1500 Max | D&P Max Waiver SOB
PPO Plus Premier Dual Choice 3 High | $1500 Max SOB
PPO Plus Premier Dual Choice 2 Voluntary | $2000 Max SOB
PPO Plus Premier Dual Choice 2 Voluntary | $1500 Max SOB
PPO Dual Choice 2 Voluntary | $2000 Max SOB
PPO Dual Choice 2 Voluntary | $1500 Max SOB
PPO Plus Premier Dual Choice 2 | $2000 Max | D&P Max Waiver SOB
PPO Plus Premier Dual Choice 2 | $2000 Max SOB
PPO Plus Premier Dual Choice 2 | $1500 Max | D&P Max Waiver SOB
PPO Plus Premier Dual Choice 2 | $1500 Max SOB
PPO Dual Choice 2 | $2000 Max | D&P Max Waiver SOB
PPO Dual Choice 2 | $2000 Max SOB
PPO Dual Choice 2 | $1500 Max | D&P Max Waiver SOB
PPO Dual Choice 2 | $1500 Max SOB
PPO Deluxe 300 | $3000 Max | D&P Max Waiver SOB
PPO Deluxe 300 | $3000 Max SOB
PPO Deluxe 300 | $2500 Max | D&P Max Waiver SOB
PPO Deluxe 300 | $2500 Max SOB
PPO Deluxe 300 | $2000 Max | D&P Max Waiver SOB
PPO Deluxe 300 | $2000 Max SOB
PPO Deluxe 300 | $1500 Max | D&P Max Waiver SOB
PPO Deluxe 300 | $1500 Max SOB
PPO Plus Premier Deluxe 200 Voluntary | $2500 Max SOB
PPO Plus Premier Deluxe 200 Voluntary | $2000 Max SOB
PPO Plus Premier Deluxe 200 Voluntary | $1500 Max SOB
PPO Deluxe 300 Voluntary | $1500 Max SOB
PPO Plus Premier Deluxe 200 | $3000 Max | D&P Max Waiver SOB
PPO Plus Premier Deluxe 200 | $2500 Max | D&P Max Waiver SOB
PPO Plus Premier Deluxe 200 | $2000 Max | D&P Max Waiver SOB
PPO Plus Premier Deluxe 200 | $1500 Max | D&P Max Waiver SOB
PPO Plus Premier Deluxe 200 | $1500 Max SOB
PPO Plus Premier Deluxe 100 | $3000 Max | D&P Max Waiver SOB
PPO Plus Premier Deluxe 100 | $1500 Max | D&P Max Waiver SOB
PPO Plus Premier Deluxe 100 | $2500 Max | D&P Max Waiver SOB
PPO Plus Premier Deluxe 100 | $2000 Max | D&P Max Waiver SOB
PPO Plus Premier Deluxe 100 Voluntary | $3000 Max SOB
PPO Plus Premier Deluxe 100 Voluntary | $2500 Max SOB
PPO Plus Premier Deluxe 100 Voluntary | $2000 Max SOB
PPO Plus Premier Deluxe 100 Voluntary | $1500 Max SOB
PPO Deluxe 300 Voluntary | $3000 Max SOB
PPO Deluxe 300 Voluntary | $2500 Max SOB
PPO Deluxe 300 Voluntary | $2000 Max SOB
PPO Deluxe 300 | $1500 Max SOB
PPO Plus Premier Deluxe 200 | $3000 Max SOB
PPO Plus Premier Deluxe 200 | $2500 Max SOB
PPO Plus Premier Deluxe 200 | $2000 Max SOB
PPO Plus Premier Deluxe 200 | $1500 Max SOB
PPO Plus Premier Deluxe 100 | $3000 Max SOB
PPO Plus Premier Deluxe 100 | $2000 Max SOB
PPO Plus Premier Deluxe 100 | $2500 Max SOB
PPO Plus Premier Deluxe 100 | $1500 Max SOB
PPO Core 200 | $1000 Max SOB
PPO Core 200 Voluntary | $1000 Max SOB
PPO Core 100 Voluntary | $1500 Max SOB
PPO Core 100 Voluntary | $1000 Max SOB
PPO Core 100 | $1500 Max SOB
PPO Core 100 | $1000 Max SOB
PPO Advantage 400 | $2500 Max | D&P Max Waiver SOB
PPO Advantage 400 | $2500 Max SOB
PPO Advantage 400 | $2000 Max | D&P Max Waiver SOB
PPO Advantage 400 | $2000 Max SOB
PPO Advantage 400 | $1500 Max | D&P Max Waiver SOB
PPO Advantage 400 | $1500 Max SOB
PPO Advantage 400 | $1000 Max | D&P Max Waiver SOB
PPO Advantage 400 | $1000 Max SOB
PPO Plus Premier Advantage 300 | $2500 Max | D&P Max Waiver SOB
PPO Plus Premier Advantage 300 | $2500 Max SOB
PPO Plus Premier Advantage 300 | $2000 Max | D&P Max Waiver SOB
PPO Plus Premier Advantage 300 | $2000 Max SOB
PPO Plus Premier Advantage 300 | $1500 Max | D&P Max Waiver SOB
PPO Plus Premier Advantage 300 | $1500 Max SOB
PPO Plus Premier Advantage 300 | $1000 Max | D&P Max Waiver SOB
PPO Plus Premier Advantage 300 | $1000 Max SOB
PPO Advantage 400 Voluntary | $2500 Max SOB
PPO Advantage 400 Voluntary | $2000 Max SOB
PPO Advantage 400 Voluntary | $1500 Max SOB
PPO Advantage 400 Voluntary | $1000 Max SOB
PPO Plus Premier Advantage 300 Voluntary | $2500 Max SOB
PPO Plus Premier Advantage 300 Voluntary | $2000 Max SOB
PPO Plus Premier Advantage 300 Voluntary | $1500 Max SOB
PPO Plus Premier Advantage 300 Voluntary | $1000 Max SOB
PPO Plus Premier Advantage 200 Voluntary | $2500 Max SOB
PPO Plus Premier Advantage 200 Voluntary | $2000 Max SOB
PPO Plus Premier Advantage 200 Voluntary | $1500 Max SOB
PPO Plus Premier Advantage 200 Voluntary | $1000 Max SOB
PPO Plus Premier Advantage 200 | $2500 Max | D&P Max Waiver SOB
PPO Plus Premier Advantage 200 | $2500 Max SOB
PPO Plus Premier Advantage 200 | $2000 Max | D&P Max Waiver SOB
PPO Plus Premier Advantage 200 | $2000 Max SOB
PPO Plus Premier Advantage 200 | $1500 Max | D&P Max Waiver SOB
PPO Plus Premier Advantage 200 | $1500 Max SOB
PPO Plus Premier Advantage 200 | $1000 Max SOB
PPO Plus Premier Advantage 200 | $1000 Max SOB
PPO Plus Premier Advantage 100 Voluntary | $2500 Max SOB
PPO Plus Premier Advantage 100 Voluntary | $2000 Max SOB
PPO Plus Premier Advantage 100 Voluntary | $1500 Max SOB
PPO Plus Premier Advantage 100 Voluntary | $1000 Max SOB
PPO Plus Premier Advantage 100 | $2500 Max | D&P Max Waiver SOB
PPO Plus Premier Advantage 100 | $2500 Max SOB
PPO Plus Premier Advantage 100 | $2000 Max | D&P Max Waiver SOB
PPO Plus Premier Advantage 100 | $2000 Max SOB
PPO Plus Premier Advantage 100 | $1500 Max | D&P Max Waiver SOB
PPO Plus Premier Advantage 100 | $1500 Max SOB
PPO Plus Premier Advantage 100 | $1000 Max | D&P Max Waiver SOB
PPO Plus Premier Advantage 100 | $1000 Max SOB
Choice Premier $1,000 without Ortho Evidence of Coverage
Choice Premier $1,000 without Ortho Plan Highlights
Choice Premier $1,500 without Ortho Evidence of Coverage
Choice Premier $1,500 without Ortho Plan Highlights
Choice Premier $2,000 without Ortho Evidence of Coverage
Choice Premier $2,000 without Ortho Plan Highlights
Choice Premier $1,000 without Ortho Evidence of Coverage
Choice PPO $1,500 without Ortho Plan Highlights
Choice Premier $1,500 without Ortho Evidence of Coverage
Choice Premier $2,000 without Ortho Evidence of Coverage
Vision: VSP
Forms
VSP Choice Plan C $200 $300 $10 $25 EZO
VSP Choice Plan C $180 $10
VSP Choice Plan C $150 $10 $25
VSP Choice Plan B $180 $10
VSP Choice Plan B $150 $20 $20
VSP Vol Signature Plan C $10 with Retail
VSP Vol Signature Plan C $10
VSP Vol Signature Enhanced Health Plan B $10
VSP Vol Signature Enhanced Health Plan B $10 with Retail
VSP Standard Signature Health Plan B $25 with Retail
VSP Signature Plan C $10
VSP Signature Plan C $10 with Retail
VSP Signature Plan C $0 $20
VSP Signature Plan C $0 $20 with Retail
VSP Signature Plan A $25
VSP Signature Plan A $25 with Retail
VSP Signature Enhanced Plan B $25
VSP Signature Enhanced Plan B $0 $20
VSP Signature Enhanced Plan B $0 $20 with Retail
VSP Vol Choice Plan C $20 $20 with Retail
VSP Vol Easy Options 5 Choice Plan C $10 $25
VSP Vol Choice Plan C $25 with Retail
VSP Vol Choice Plan C $10 $25 with Retail
VSP Vol Choice Enhanced Plan B $180, $10 $25 with Retail
VSP Vol Choice Enhanced Plan B $150, $10 $25 with Retail
VSP Vol Choice Enhanced Plan B $20 $20
VSP Vol Choice Enhanced Plan B $20 $20 with Retail
VSP Standard Choice Plan C $130, $25 with Retail
VSP Elite Choice Plan C $25 with Retail
VSP Elite Choice Enhanced Plan B $25 with Retail
VSP Easy Option 5 Choice Plan C $10 $25
VSP Choice Plan A $25 $25
VSP Choice Plan A $25 $25 with Retail
VSP Choice Plan A $20
VSP Basic Choice Plan A $20 with Retail
VSP Basic Choice Enhanced Plan B $130, $25 with Retail
CoPower VSP EasyOptions Plan Summary
Chiro/Acu: Landmark
Forms
Chiropractic Schedule of Benefits $25 20 Plan Highlights
Chiropractic Schedule of Benefits $25 15 Plan Highlights
Chiropractic Schedule of Benefits $25 10 Plan Highlights
Acupunture Schedule of Benefits $35 20 Plan Hightlights
Acupunture Schedule of Benefits $35 15 Plan Hightlights
Acupunture Schedule of Benefits $35 10 Plan Hightlights
Combined Schedule of Benefits $15 20 Plan Highlights
Combined Schedule of Benefits $15 30 Plan Highlights
Combined Schedule of Benefits $20 20 Plan Highlights
Combined Schedule of Benefits $20 30 Plan Highlights
Acupuncture Schedule of Benefits $10 20 Plan Highlights
Acupuncture Schedule of Benefits $10 30 Plan Highlights
Acupuncture Schedule of Benefits $15 20 Plan Highlights
Acupuncture Schedule of Benefits $15 30 Plan Highlights
Acupuncture Schedule of Benefits $20 20 Plan Highlights
Acupuncture Schedule of Benefits $20 30 Plan Highlights
Chiropractic Schedule of Benefits $10 20 Plan Highlights
Chiropractic Schedule of Benefits $10 30 Plan Highlights
Chiropractic Schedule of Benefits $15 20 Plan Highlights
Chiropractic Schedule of Benefits $15 30 Plan Highlights
Chiropractic Schedule of Benefits $20 20 Plan Highlights
Chiropractic Schedule of Benefits $20 30 Plan Highlights
Combined Schedule of Benefits $10 20 Plan Highlights
Combined Schedule of Benefits $10 30 Plan Highlights
Combined Schedule of Benefits $15 20 Plan Highlights
Combined Schedule of Benefits $15 30 Plan Highlights
Combined Schedule of Benefits $20 20 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
Acupuncture Schedule of Benefits $10 20 Plan Highlights
Acupuncture Schedule of Benefits $10 30 Plan Highlights
Acupuncture Schedule of Benefits $15 20 Plan Highlights
Acupuncture Schedule of Benefits $15 30 Plan Highlights
Acupuncture Schedule of Benefits $20 20 Plan Highlights
Acupuncture Schedule of Benefits $20 30 Plan Highlights
Chiropractic Schedule of Benefits $10 20 Plan Highlights
Chiropractic Schedule of Benefits $10 30 Plan Highlights
Chiropractic Schedule of Benefits $15 20 Plan Highlight
Chiropractic Schedule of Benefits $15 30 Plan Highlights
Chiropractic Schedule of Benefits $20 20 Plan Highlight
Chiropractic Schedule of Benefits $20 30 Plan Highlights
Combined Schedule of Benefits $10 20 Plan Highlights
Combined Schedule of Benefits $10 30 Plan Highlights
Dental PPO w/Ortho: Delta Dental
Forms
PPO Plus Premier Dual Choice Buy-up | $2000 Max | $1500 Ortho SOB
PPO Dual Choice Buy-up | $2000 Max | $1500 Ortho SOB
PPO Plus Premier Dual Choice Buy-up | $1500 Max | $1500 Ortho SOB
PPO Dual Choice Buy-up | $1500 Max | $1500 Ortho SOB
PPO Plus Premier Dual Choice Core | $1000 Max | $1000 Ortho SOB
PPO Dual Choice Core | $1000 Max | $1000 Ortho SOB
PPO Plus Premier Dual Choice 3 Voluntary | $2500 Max | $1500 Ortho SOB
PPO Plus Premier Dual Choice 3 Voluntary | $1500 Max | $1500 Ortho SOB
PPO Plus Premier Dual Choice 3 Voluntary | $1500 Max | $1000 Ortho SOB
PPO Plus Premier Dual Choice 3 Voluntary | $1000 Max | $100 Ortho SOB - needs to be $1000 ortho
PPO Plus Premier Dual Choice 3 Low | $1500 Max | D&P Max Waiver | $1000 Ortho SOB
PPO Plus Premier Dual Choice 3 Low | $1500 Max | $1000 Ortho SOB
PPO Plus Premier Dual Choice 3 Low | $1000 Max | D&P Max Waiver | $1000 Ortho SOB
PPO Plus Premier Dual Choice 3 Low | $1000 Max | $1000 Ortho SOB
PPO Plus Premier Dual Choice 3 Low | $1000 Max | $1000 Ortho SOB
PPO Plus Premier Dual Choice 3 High | $2500 Max | D&P Max Waiver | $1500 Ortho SOB
PPO Plus Premier Dual Choice 3 High | $2500 Max | $1500 Ortho SOB
PPO Plus Premier Dual Choice 3 High | $1500 Max | D&P Max Waiver | $1500 Ortho SOB
PPO Plus Premier Dual Choice 3 High | $1500 Max | $1500 Ortho SOB
PPO Plus Premier Dual Choice 2 Voluntary | $2000 Max | $1000 Ortho SOB
PPO Plus Premier Dual Choice 2 Voluntary | $1500 Max | $1000 Ortho SOB
PPO Dual Choice 2 Voluntary | $2000 Max | $1000 Ortho SOB
PPO Dual Choice 2 Voluntary | $1500 Max | $1000 Ortho SOB
PPO Plus Premier Dual Choice 2 | $2000 Max | D&P Max Waiver | $1000 Ortho SOB
PPO Plus Premier Dual Choice 2 | $2000 Max | $1000 Ortho SOB
PPO Plus Premier Dual Choice 2 | $1500 Max | D&P Max Waiver | $1000 Ortho SOB
PPO Plus Premier Dual Choice 2 | $1500 Max | $1000 Ortho SOB
PPO Dual Choice 2 | $2000 Max | D&P Max Waiver | $1000 Ortho SOB
PPO Dual Choice 2 | $2000 Max | $1000 Ortho SOB
PPO Dual Choice 2 | $1500 Max | D&P Max Waiver | $1000 Ortho SOB
PPO Dual Choice 2 | $1500 Max | $1000 Ortho SOB
PPO Deluxe 300 | $3000 Max | D&P Max Waiver | $1500 Child Ortho SOB
PPO Deluxe 300 | $3000 Max | D&P Max Waiver | $1500 Child and Adult Ortho SOB
PPO Deluxe 300 | $3000 Max | $1500 Child Ortho SOB
PPO Deluxe 300 | $3000 Max | $1500 Child and Adult Ortho SOB
PPO Deluxe 300 | $2500 Max | D&P Max Waiver | $1500 Child Ortho SOB
PPO Deluxe 300 | $2500 Max | D&P Max Waiver | $1500 Child and Adult Ortho SOB
PPO Deluxe 300 | $2500 Max | $1500 Child Ortho SOB
PPO Deluxe 300 | $2500 Max | $1500 Child and Adult 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 | $2000 Max | $1500 Child and Adult Ortho SOB
PPO Deluxe 300 | $2000 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 | $1500 Max | $1500 Child Ortho SOB
PPO Deluxe 300 | $1500 Max | $1500 Child and Adult Ortho SOB
PPO Plus Premier Deluxe 200 Voluntary | $3000 Max | $1500 Child Ortho SOB
PPO Plus Premier Deluxe 200 Voluntary | $3000 Max | $1500 Child and Adult Ortho SOB
PPO Plus Premier Deluxe 200 Voluntary | $3000 Max SOB
PPO Plus Premier Deluxe 200 Voluntary | $2500 Max | $1500 Child Ortho SOB
PPO Plus Premier Deluxe 200 Voluntary | $2500 Max | $1500 Child and Adult Ortho SOB
PPO Plus Premier Deluxe 200 Voluntary | $2000 Max | $1500 Child and Adult Ortho SOB
PPO Plus Premier Deluxe 200 Voluntary | $2000 Max | $1500 Child Ortho SOB
PPO Plus Premier Deluxe 200 Voluntary | $1500 Max | $1500 Child and Adult Ortho SOB
PPO Plus Premier Deluxe 200 Voluntary | $1500 Max | $1500 Child Ortho SOB
PPO Deluxe 300 Voluntary | $2500 Max | $1500 Child Ortho SOB
PPO Deluxe 300 Voluntary | $1500 Max | $1500 Child and Adult Ortho SOB
PPO Deluxe 300 Voluntary | $1500 Max | $1500 Child Ortho SOB
PPO Plus Premier Deluxe 200 | $3000 Max | D&P Max Waiver | $1500 Child Ortho SOB
PPO Plus Premier Deluxe 200 | $3000 Max | D&P Max Waiver | $1500 Child and Adult Ortho SOB
PPO Plus Premier Deluxe 200 | $2500 Max | D&P Max Waiver | $1500 Child and Adult Ortho SOB
PPO Plus Premier Deluxe 200 | $2000 Max | D&P Max Waiver | $1500 Child Ortho SOB
PPO Plus Premier Deluxe 200 | $2000 Max | D&P Max Waiver | $1500 Child and Adult Ortho SOB
PPO Plus Premier Deluxe 200 | $1500 Max | D&P Max Waiver | $1500 Child Ortho SOB
PPO Plus Premier Deluxe 200 | $1500 Max | D&P Max Waiver | $1500 Child and Adult Ortho SOB
PPO Plus Premier Deluxe 200 | $1500 Max | $1500 Child Ortho SOB
PPO Plus Premier Deluxe 200 | $1500 Max | $1500 Child and Adult Ortho SOB
PPO Plus Premier Deluxe 100 | $3000 Max | D&P Max Waiver | $1500 Child Ortho SOB
PPO Plus Premier Deluxe 100 | $3000 Max | D&P Max Waiver | $1500 Child and Adult Ortho SOB
PPO Plus Premier Deluxe 100 | $1500 Max | D&P Max Waiver | $1500 Child Ortho SOB
PPO Plus Premier Deluxe 100 | $1500 Max | D&P Max Waiver | $1500 Child and Adult Ortho SOB
PPO Plus Premier Deluxe 100 | $2500 Max | D&P Max Waiver | $1500 Child Ortho SOB
PPO Plus Premier Deluxe 100 | $2500 Max | D&P Max Waiver | $1500 Child and Adult Ortho SOB
PPO Plus Premier Deluxe 100 | $2000 Max | D&P Max Waiver | $1500 Child and Adult Ortho SOB
PPO Plus Premier Deluxe 100 | $2000 Max | D&P Max Waiver | $1500 Child Ortho SOB
PPO Plus Premier Deluxe 100 Voluntary | $3000 Max | $1500 Child Ortho SOB
PPO Plus Premier Deluxe 100 Voluntary | $3000 Max | $1500 Child and Adult Ortho SOB
PPO Plus Premier Deluxe 100 Voluntary | $2500 Max | $1500 Child and Adult Ortho SOB
PPO Plus Premier Deluxe 100 Voluntary | $2500 Max | $1500 Child Ortho SOB
PPO Plus Premier Deluxe 100 Voluntary | $2000 Max | $1500 Child and Adult Ortho SOB
PPO Plus Premier Deluxe 100 Voluntary | $2000 Max | $1500 Child Ortho SOB
PPO Plus Premier Deluxe 100 Voluntary | $1500 Max | $1500 Child and Adult Ortho SOB
PPO Plus Premier Deluxe 100 Voluntary | $1500 Max | $1500 Child Ortho SOB
PPO Deluxe 300 Voluntary | $3000 Max | $1500 Child Ortho SOB
PPO Deluxe 300 Voluntary | $3000 Max | $1500 Child and Adult Ortho SOB
PPO Deluxe 300 | $2500 Max | $1500 Child Ortho SOB
PPO Deluxe 300 Voluntary | $2500 Max | $1500 Child and Adult Ortho SOB
PPO Deluxe 300 Voluntary | $2000 Max | $1500 Child Ortho SOB
PPO Deluxe 300 Voluntary | $2000 Max | $1500 Child and Adult Ortho SOB
PPO Deluxe 300 | $1500 Max | $1500 Child Ortho SOB
PPO Deluxe 300 | $1500 Max | $1500 Child and Adult Ortho SOB
PPO Plus Premier Deluxe 200 | $3000 Max | $1500 Child Ortho SOB
PPO Plus Premier Deluxe 200 | $3000 Max | $1500 Child and Adult Ortho SOB
PPO Plus Premier Deluxe 200 | $2500 Max | $1500 Child Ortho SOB
PPO Plus Premier Deluxe 200 | $2500 Max | $1500 Child and Adult Ortho SOB
PPO Plus Premier Deluxe 200 | $2000 Max | $1500 Child Ortho SOB
PPO Plus Premier Deluxe 200 | $2000 Max | $1500 Child and Adult Ortho SOB
PPO Plus Premier Deluxe 200 | $1500 Max | $1500 Child Ortho SOB
PPO Plus Premier Deluxe 200 | $1500 Max | $1500 Child and Adult Ortho SOB
PPO Plus Premier Deluxe 100 | $3000 Max | $1500 Child Ortho SOB
PPO Plus Premier Deluxe 100 | $3000 Max | $1500 Child and Adult Ortho SOB
PPO Plus Premier Deluxe 100 | $2500 Max | $1500 Child Ortho SOB
PPO Plus Premier Deluxe 100 | $2500 Max | $1500 Child and Adult Ortho SOB
PPO Plus Premier Deluxe 100 | $2000 Max | $1500 Child Ortho SOB
PPO Plus Premier Deluxe 100 | $2000 Max | $1500 Child and Adult Ortho SOB
PPO Plus Premier Deluxe 100 | $1500 Max | $1500 Child Ortho SOB
PPO Plus Premier Deluxe 100 | $1500 Max | $1500 Child and Adult Ortho SOB
PPO Advantage 400 | $2500 Max | D&P Max Waiver | $1500 Ortho SOB
PPO Advantage 400 | $2500 Max | D&P Max Waiver | $1000 Ortho SOB
PPO Advantage 400 | $2500 Max | $1500 Ortho SOB
PPO Advantage 400 | $2500 Max | $1000 Ortho SOB
PPO Advantage 400 | $2000 Max | D&P Max Waiver | $1500 Ortho SOB
PPO Advantage 400 | $2000 Max | D&P Max Waiver | $1000 Ortho SOB
PPO Advantage 400 | $2000 Max | $1500 Ortho SOB
PPO Advantage 400 | $2000 Max | $1000 Ortho SOB
PPO Advantage 400 | $1500 Max | D&P Max Waiver | $1500 Ortho SOB
PPO Advantage 400 | $1500 Max | D&P Max Waiver | $1000 Ortho SOB
PPO Advantage 400 | $1500 Max | $1500 Ortho SOB
PPO Advantage 400 | $1500 Max | $1000 Ortho SOB
PPO Advantage 400 | $1000 Max | D&P Max Waiver | $1500 Ortho SOB
PPO Advantage 400 | $1000 Max | D&P Max Waiver | $1000 Ortho SOB
PPO Advantage 400 | $1000 Max | $1500 Ortho SOB
PPO Advantage 400 | $1000 Max | $1000 Ortho SOB
PPO Plus Premier Advantage 300 | $2500 Max | D&P Max Waiver | $1500 Ortho SOB
PPO Plus Premier Advantage 300 | $2500 Max | D&P Max Waiver | $1000 Ortho SOB
PPO Plus Premier Advantage 300 | $2500 Max | $1500 Ortho SOB
PPO Plus Premier Advantage 300 | $2500 Max | $1000 Ortho SOB
PPO Plus Premier Advantage 300 | $2000 Max | D&P Max Waiver | $1500 Ortho SOB
PPO Plus Premier Advantage 300 | $2000 Max | D&P Max Waiver | $1000 Ortho SOB
PPO Plus Premier Advantage 300 | $2000 Max | $1500 Ortho SOB
PPO Plus Premier Advantage 300 | $2000 Max | $1000 Ortho SOB
PPO Plus Premier Advantage 300 | $1500 Max | D&P Max Waiver | $1500 Ortho SOB
PPO Plus Premier Advantage 300 | $1500 Max | D&P Max Waiver | $1000 Ortho SOB
PPO Plus Premier Advantage 300 | $1500 Max | $1500 Ortho SOB
PPO Plus Premier Advantage 300 | $1500 Max | $1000 Ortho SOB
PPO Plus Premier Advantage 300 | $1000 Max | D&P Max Waiver | $1500 Ortho SOB
PPO Plus Premier Advantage 300 | $1000 Max | D&P Max Waiver | $1000 Ortho SOB
PPO Plus Premier Advantage 300 | $1000 Max | $1500 Ortho SOB
PPO Plus Premier Advantage 300 | $1000 Max | $1000 Ortho SOB
PPO Advantage 400 Voluntary | $2500 Max | $1500 Ortho SOB
PPO Advantage 400 Voluntary | $2500 Max | $1000 Ortho SOB
PPO Advantage 400 Voluntary | $2000 Max | $1500 Ortho SOB
PPO Advantage 400 Voluntary | $2000 Max | $1000 Ortho SOB
PPO Advantage 400 Voluntary | $1500 Max | $1500 Ortho SOB
PPO Advantage 400 Voluntary | $1500 Max | $1000 Ortho SOB
PPO Advantage 400 Voluntary | $1000 Max | $1500 Ortho SOB
PPO Advantage 400 Voluntary | $1000 Max | $1000 Ortho SOB
PPO Plus Premier Advantage 300 Voluntary | $2500 Max | $1500 Ortho SOB
PPO Plus Premier Advantage 300 Voluntary | $2500 Max | $1000 Ortho SOB
PPO Plus Premier Advantage 300 Voluntary | $2000 Max | $1500 Ortho SOB
PPO Plus Premier Advantage 300 Voluntary | $2000 Max | $1000 Ortho SOB
PPO Plus Premier Advantage 300 Voluntary | $1500 Max | $1500 Ortho SOB
PPO Plus Premier Advantage 300 Voluntary | $1500 Max | $1000 Ortho SOB
PPO Plus Premier Advantage 300 Voluntary | $1000 Max | $1500 Ortho SOB
PPO Plus Premier Advantage 300 Voluntary | $1000 Max | $1000 Ortho SOB
PPO Plus Premier Advantage 200 Voluntary | $2500 Max | $1500 Ortho SOB
PPO Plus Premier Advantage 200 Voluntary | $2500 Max | $1000 Ortho SOB
PPO Plus Premier Advantage 200 Voluntary | $2000 Max | $1500 Ortho SOB
PPO Plus Premier Advantage 200 Voluntary | $2000 Max | $1000 Ortho SOB
PPO Plus Premier Advantage 200 Voluntary | $1500 Max | $1500 Ortho SOB
PPO Plus Premier Advantage 200 Voluntary | $1500 Max | $1000 Ortho SOB
PPO Plus Premier Advantage 200 Voluntary | $1000 Max | $1500 Ortho SOB
PPO Plus Premier Advantage 200 Voluntary | $1000 Max | $1000 Ortho SOB
PPO Plus Premier Advantage 200 | $2500 Max | D&P Max Waiver | $1500 Ortho SOB
PPO Plus Premier Advantage 200 | $2500 Max | D&P Max Waiver | $1000 Ortho SOB
PPO Plus Premier Advantage 200 | $2500 Max | $1500 Ortho SOB
PPO Plus Premier Advantage 200 | $2500 Max | $1000 Ortho SOB
PPO Plus Premier Advantage 200 | $2000 Max | D&P Max Waiver | $1500 Ortho SOB
PPO Plus Premier Advantage 200 | $2000 Max | D&P Max Waiver | $1000 Ortho SOB
PPO Plus Premier Advantage 200 | $2000 Max | $1500 Ortho SOB
PPO Plus Premier Advantage 200 | $2000 Max | $1000 Ortho SOB
PPO Plus Premier Advantage 200 | $1500 Max | D&P Max Waiver | $1500 Ortho SOB
PPO Plus Premier Advantage 200 | $1500 Max | D&P Max Waiver | $1000 Ortho SOB
PPO Plus Premier Advantage 200 | $1500 Max | $1500 Ortho SOB
PPO Plus Premier Advantage 200 | $1500 Max | $1000 Ortho SOB
PPO Plus Premier Advantage 200 | $1000 Max | D&P Max Waiver | $1500 Ortho SOB
PPO Plus Premier Advantage 200 | $1000 Max | D&P Max Waiver | $1000 Ortho SOB
PPO Plus Premier Advantage 200 | $1000 Max | $1500 Ortho SOB
PPO Plus Premier Advantage 200 | $1000 Max | $1000 Ortho SOB
PPO Plus Premier Advantage 100 Voluntary | $2500 Max | $1500 Ortho SOB
PPO Plus Premier Advantage 100 Voluntary | $2500 Max | $1000 Ortho SOB
PPO Plus Premier Advantage 100 Voluntary | $2000 Max | $1500 Ortho SOB
PPO Plus Premier Advantage 100 Voluntary | $2000 Max | $1000 Ortho SOB
PPO Plus Premier Advantage 100 Voluntary | $1500 Max | $1500 Ortho SOB
PPO Plus Premier Advantage 100 Voluntary | $1500 Max | $1000 Ortho SOB
PPO Plus Premier Advantage 100 Voluntary | $1000 Max | $1500 Ortho SOB
PPO Plus Premier Advantage 100 Voluntary | $1000 Max | $1000 Ortho SOB
PPO Plus Premier Advantage 100 | $2500 Max | D&P Max Waiver | $1500 Ortho SOB
PPO Plus Premier Advantage 100 | $2500 Max | D&P Max Waiver | $1000 Ortho SOB
PPO Plus Premier Advantage 100 | $2500 Max | $1500 Ortho SOB
PPO Plus Premier Advantage 100 | $2500 Max | $1000 Ortho SOB
PPO Plus Premier Advantage 100 | $2000 Max | D&P Max Waiver | $1500 Ortho SOB
PPO Plus Premier Advantage 100 | $2000 Max | D&P Max Waiver | $1000 Ortho SOB
PPO Plus Premier Advantage 100 | $2000 Max | $1500 Ortho SOB
PPO Plus Premier Advantage 100 | $2000 Max | $1000 Ortho SOB
PPO Plus Premier Advantage 100 | $1500 Max | D&P Max Waiver | $1500 Ortho SOB
PPO Plus Premier Advantage 100 | $1500 Max | D&P Max Waiver | $1000 Ortho SOB
PPO Plus Premier Advantage 100 | $1500 Max | $1500 Ortho SOB
PPO Plus Premier Advantage 100 | $1500 Max | $1000 Ortho SOB
PPO Plus Premier Advantage 100 | $1000 Max | D&P Max Waiver | $1500 Ortho SOB
PPO Plus Premier Advantage 100 | $1000 Max | D&P Max Waiver | $1000 Ortho SOB
PPO Plus Premier Advantage 100 | $1000 Max | $1500 Ortho SOB
PPO Plus Premier Advantage 100 | $1000 Max | $1000 Ortho SOB
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 Plan Highlights
Choice PPO $1,000 with Ortho Plan Highlights
Choice PPO $1,000 without Ortho Plan Highlights
Choice Premier $1,000 with Ortho Evidence of Coverage
Choice PPO $1,500 with Ortho Plan Highlights
Choice Premier $1,500 with Ortho Evidence of Coverage
Choice PPO $2,000 with Ortho Plan Highlights
Choice PPO $2,000 without Ortho Plan Highlights
Choice Premier $2,000 with Ortho Evidence of Coverage
Choice Premier $1,000 with Ortho Evidence of Coverage
Choice Premier $1,000 with Ortho Plan Highlights
Life: Unum
Forms
Unum Group Term Life Plan Highlights
In-Force Group Materials
Employee Forms
Forms
VSP Out-of-Network Reimbursement Form (Spanish)
Existing Group Enrollment and Change Form (Spanish)
Unum Waiver of Premium Claim Form
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
Delta Dental HIPAA Authorization
Employer Forms
Forms
Direct Debit Authorization Form
One Time Bank Draft Authorization Form
Group Cancellation Form
Renewal Date Change Request Form
Group Address Change Form
Federal COBRA and CalCOBRA Status Notification Form
Unum Notification of Conversion Form
VSP Affiliate Census (Use only for existing VSP groups adding the Affiliate program)
Employee Termination Form
Employer Administration
Forms
CoPower Contact Sheet
Unum Life & AD&D Claim Form 
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