Forms & Documents

Summary of Benefits (SOB)

Dental HMO: Delta Dental

	CoPower ONE DeltaCare Platinum Plan Highlights w/$25K Life
	CoPower ONE DeltaCare Platinum Plan Highlights w/$35K Life
	CoPower ONE DeltaCare Platinum Plan Highlights w/$50K Life
	CoPower ONE DeltaCare Silver/Gold Plan Highlights w/$100K Life
	CoPower ONE DeltaCare Silver/Gold Plan Highlights w/$150K Life
	CoPower ONE DeltaCare Silver/Gold Plan Highlights w/$20K Life
	CoPower ONE DeltaCare Silver/Gold Plan Highlights w/$35K Life
	CoPower ONE DeltaCare Silver/Gold Plan Highlights w/$50K Life
	CoPower ONE DeltaCare Voluntary Highlights
	CoPower ONE DeltaCare Voluntary Highlights - New York
	CoPower ONE DeltaCare Voluntary Plan Highlights - New York
	DHMO Advantage 15B SOB
	DHMO Core 17B SOB
	DHMO Deluxe 11A SOB

Dental PPO w/Ortho: Delta Dental

	Choice PPO $1,000 with Ortho Plan Highlights
	Choice PPO $1,000 without Ortho Plan Highlights
	Choice PPO $1,500 with Ortho Plan Highlights
	Choice PPO $2,000 with Ortho Plan Highlights
	Choice PPO $2,000 without Ortho Plan Highlights
	Choice Premier $1,000 with Ortho Evidence of Coverage
	Choice Premier $1,000 with Ortho Evidence of Coverage
	Choice Premier $1,000 with Ortho Plan Highlights
	Choice Premier $1,500 with Ortho Evidence of Coverage
	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 Evidence of Coverage
	Choice Premier $2,000 with Ortho Plan Highlights
	PPO Advantage 400 | $1000 Max | $1000 Ortho SOB
	PPO Advantage 400 | $1000 Max | $1500 Ortho SOB
	PPO Advantage 400 | $1000 Max | D&P Max Waiver | $1000 Ortho SOB
	PPO Advantage 400 | $1000 Max | D&P Max Waiver | $1500 Ortho SOB
	PPO Advantage 400 | $1500 Max | $1000 Ortho SOB
	PPO Advantage 400 | $1500 Max | $1500 Ortho SOB
	PPO Advantage 400 | $1500 Max | D&P Max Waiver | $1000 Ortho SOB
	PPO Advantage 400 | $1500 Max | D&P Max Waiver | $1500 Ortho SOB
	PPO Advantage 400 | $2000 Max | $1000 Ortho SOB
	PPO Advantage 400 | $2000 Max | $1500 Ortho SOB
	PPO Advantage 400 | $2000 Max | D&P Max Waiver | $1000 Ortho SOB
	PPO Advantage 400 | $2000 Max | D&P Max Waiver | $1500 Ortho SOB
	PPO Advantage 400 | $2500 Max | $1000 Ortho SOB
	PPO Advantage 400 | $2500 Max | $1500 Ortho SOB
	PPO Advantage 400 | $2500 Max | D&P Max Waiver | $1000 Ortho SOB
	PPO Advantage 400 | $2500 Max | D&P Max Waiver | $1500 Ortho SOB
	PPO Advantage 400 Voluntary | $1000 Max | $1000 Ortho SOB
	PPO Advantage 400 Voluntary | $1000 Max | $1500 Ortho SOB
	PPO Advantage 400 Voluntary | $1500 Max | $1000 Ortho SOB
	PPO Advantage 400 Voluntary | $1500 Max | $1500 Ortho SOB
	PPO Advantage 400 Voluntary | $2000 Max | $1000 Ortho SOB
	PPO Advantage 400 Voluntary | $2000 Max | $1500 Ortho SOB
	PPO Advantage 400 Voluntary | $2500 Max | $1000 Ortho SOB
	PPO Advantage 400 Voluntary | $2500 Max | $1500 Ortho SOB
	PPO Deluxe 300 | $1500 Max | $1500 Child and Adult Ortho SOB
	PPO Deluxe 300 | $1500 Max | $1500 Child and Adult Ortho SOB
	PPO Deluxe 300 | $1500 Max | $1500 Child Ortho SOB
	PPO Deluxe 300 | $1500 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 | $2000 Max | $1500 Child and Adult Ortho SOB
	PPO Deluxe 300 | $2000 Max | $1500 Child 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 | $2500 Max | $1500 Child and Adult Ortho SOB
	PPO Deluxe 300 | $2500 Max | $1500 Child Ortho SOB
	PPO Deluxe 300 | $2500 Max | $1500 Child Ortho SOB
	PPO Deluxe 300 | $2500 Max | D&P Max Waiver | $1500 Child and Adult Ortho SOB
	PPO Deluxe 300 | $2500 Max | D&P Max Waiver | $1500 Child Ortho SOB
	PPO Deluxe 300 | $3000 Max | $1500 Child and Adult Ortho SOB
	PPO Deluxe 300 | $3000 Max | $1500 Child Ortho SOB
	PPO Deluxe 300 | $3000 Max | D&P Max Waiver | $1500 Child and Adult Ortho SOB
	PPO Deluxe 300 | $3000 Max | D&P Max Waiver | $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 Deluxe 300 Voluntary | $2000 Max | $1500 Child and Adult Ortho SOB
	PPO Deluxe 300 Voluntary | $2000 Max | $1500 Child Ortho SOB
	PPO Deluxe 300 Voluntary | $2500 Max | $1500 Child and Adult Ortho SOB
	PPO Deluxe 300 Voluntary | $2500 Max | $1500 Child Ortho SOB
	PPO Deluxe 300 Voluntary | $3000 Max | $1500 Child and Adult Ortho SOB
	PPO Deluxe 300 Voluntary | $3000 Max | $1500 Child Ortho SOB
	PPO Dual Choice 2 | $1500 Max | $1000 Ortho SOB
	PPO Dual Choice 2 | $1500 Max | D&P Max Waiver | $1000 Ortho SOB
	PPO Dual Choice 2 | $2000 Max | $1000 Ortho SOB
	PPO Dual Choice 2 | $2000 Max | D&P Max Waiver | $1000 Ortho SOB
	PPO Dual Choice 2 Voluntary | $1500 Max | $1000 Ortho SOB
	PPO Dual Choice 2 Voluntary | $2000 Max | $1000 Ortho SOB
	PPO Dual Choice Buy-up | $1500 Max | $1500 Ortho SOB
	PPO Dual Choice Buy-up | $2000 Max | $1500 Ortho SOB
	PPO Dual Choice Core | $1000 Max | $1000 Ortho SOB
	PPO Plus Premier Advantage 100 | $1000 Max | $1000 Ortho SOB
	PPO Plus Premier Advantage 100 | $1000 Max | $1500 Ortho SOB
	PPO Plus Premier Advantage 100 | $1000 Max | D&P Max Waiver | $1000 Ortho SOB
	PPO Plus Premier Advantage 100 | $1000 Max | D&P Max Waiver | $1500 Ortho SOB
	PPO Plus Premier Advantage 100 | $1500 Max | $1000 Ortho SOB
	PPO Plus Premier Advantage 100 | $1500 Max | $1500 Ortho SOB
	PPO Plus Premier Advantage 100 | $1500 Max | D&P Max Waiver | $1000 Ortho SOB
	PPO Plus Premier Advantage 100 | $1500 Max | D&P Max Waiver | $1500 Ortho SOB
	PPO Plus Premier Advantage 100 | $2000 Max | $1000 Ortho SOB
	PPO Plus Premier Advantage 100 | $2000 Max | $1500 Ortho SOB
	PPO Plus Premier Advantage 100 | $2000 Max | D&P Max Waiver | $1000 Ortho SOB
	PPO Plus Premier Advantage 100 | $2000 Max | D&P Max Waiver | $1500 Ortho SOB