Forms & Documents

Broker Materials

Appointment & Commission

	Broker-Agency Direct Deposit Authorization Form
	CoPower Producer Agreement CA

Enrollment Forms

Employee

	Benefit Waiver and Declination 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)
	VSP Out-of-Network Reimbursement Form
	VSP Out-of-Network Reimbursement 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
	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

	CoPower ONE Product and Rate Guide 2025 - California
	CoPower SELECT VSP Product and Rate Guide 2025

Brochures/Flyers: Broker/Employer

	CoPower ONE Pick One Flyer CA Region 1
	CoPower ONE Pick One Flyer CA Region 2
	CoPower Portfolio
	Empower Group Flyer
	VSP Plan Comparison Signature and Choice

Brochures/Flyers: Member

	VSP EasyOptions
	VSP Essential Medical Eye Care (Member)
	VSP Eyeconic
	VSP Eyeconic Save Time and Money
	VSP Freedom to Choose with Retail
	VSP Put Your Eyes At Ease with VSP LightCare (Member)
	VSP Ultimate Provider Playlist with Retail
	VSP/CoPower - See Well. Be Well.
	VSP/CoPower Your Vision Coverage Works Overtime

Summary of Benefits (SOB)

Vision: VSP

	CoPower VSP EasyOptions Plan Summary
	VSP Basic Choice Enhanced Plan B $130, $25 with Retail
	VSP Basic Choice Plan A $20 with Retail
	VSP Choice Plan A $20
	VSP Choice Plan A $25 $25
	VSP Choice Plan A $25 $25 with Retail
	VSP Choice Plan B $150 $20 $20
	VSP Choice Plan B $180 $10
	VSP Choice Plan C $150 $10 $25
	VSP Choice Plan C $180 $10
	VSP Choice Plan C $200 $300 $10 $25 EZO
	VSP Easy Option 5 Choice Plan C $10 $25
	VSP Elite Choice Enhanced Plan B $25 with Retail
	VSP Elite Choice Plan C $25 with Retail
	VSP Signature Enhanced Plan B $0 $20
	VSP Signature Enhanced Plan B $0 $20 with Retail
	VSP Signature Enhanced Plan B $25
	VSP Signature Plan A $25
	VSP Signature Plan A $25 with Retail
	VSP Signature Plan C $0 $20
	VSP Signature Plan C $0 $20 with Retail
	VSP Signature Plan C $10
	VSP Signature Plan C $10 with Retail
	VSP Standard Choice Plan C $130, $25 with Retail
	VSP Standard Signature Health Plan B $25 with Retail
	VSP Vol Choice Enhanced Plan B $150, $10 $25 with Retail
	VSP Vol Choice Enhanced Plan B $180, $10 $25 with Retail
	VSP Vol Choice Enhanced Plan B $20 $20
	VSP Vol Choice Enhanced Plan B $20 $20 with Retail
	VSP Vol Choice Plan C $10 $25 with Retail
	VSP Vol Choice Plan C $20 $20 with Retail
	VSP Vol Choice Plan C $25 with Retail
	VSP Vol Easy Options 5 Choice Plan C $10 $25
	VSP Vol Signature Enhanced Health Plan B $10
	VSP Vol Signature Enhanced Health Plan B $10 with Retail
	VSP Vol Signature Plan C $10
	VSP Vol Signature Plan C $10 with Retail