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 (January 2025 to December 2025)

Enrollment Forms

Employee

	Benefit Waiver and Declination Form
	Declaration of Disability Over-Age Dependent Child Form
	New Group Enrollment/Waiver Form
	New Group Enrollment/Waiver Form (Spanish)

Employer

	CoPower Enrollment Census (All Carriers) - California
	CoPower SELECT Employer Application with Delta Dental, VSP, UNUM, & Landmark
	W-9 Form

In-Force Group Materials

Employee Forms

	Existing Group Enrollment and Change Form
	Existing Group Enrollment and Change Form (Spanish)

Employer Administration

CoPower Contact Sheet

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

Sales Guides & Flyers

Value Add Programs

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

Product Guides

CoPower SELECT Landmark Product and Rate Guide (January 1 – December 31, 2025)

Brochures/Flyers: Broker/Employer

	CoPower Portfolio
	Empower Group Flyer

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