1. finance
2. bank
3. bank account

CoPower Administration Authorization Form
(Anthem Blue Cross Dental, Vision, and Life)
The CoPower Advantage:
Exclusive 6% multiline discount on Anthem ancillary plans*
VANTAGE, a portfolio of value-add products free to all CoPower members
dedicated customer service
y offerings, and benefit from one bill and
one point of contact.
*6% discount on all ancillary lines is available for groups that enroll in Anthem Dental plus Anthem Vision and/or Anthem Life (10+). Discount only
applies to Life when 10 or more are enrolled. Eligible plan pairings for the multiline discount are Dental + Vision, Dental + Vision + Life (10+), Dental
+ Life (10+).
Note: Groups will receive separate group numbers and bills if enrolled in both Anthem Medical and Anthem Ancillary with administration through
CoPower.
Group Information
Company:
HRAnswerLink Enrollment (Free Online HR Support):
Yes
No
Payment
Invoices How would you like to receive invoices?
Mail
E-mail
Both If E-mail/Both selected please complete the following:
Contact Name
Email address
The above information will be used to authenticate access to the invoice. You must notify CoPower if this contact or e-mail address changes.
Initial Payment Please make check payable to CoPower and submit with your Employer Application and any other enrollment paperwork. This is
a pre-paid plan. Monthly payments are due no later than the first day of the coverage month.
Ongoing Payment Do you wish to have your monthly invoice amount automatically debited from your company account?
Yes
No
If yes, please complete the following. Allow up to one billing cycle to process your request. You must continue to submit your payment until
your invoice indicates that the amount due will be debited from your account.
Bank Account Information (must be a Checking Account)
Account Holder’s Name (if different from above):
Name of Bank:
Bank Address:
Bank Routing Number:
Account Number:
I hereby authorize CoPower to initiate debits from the account identified above. I understand it remains in effect until I give written notice to
CoPower, which I must do by the 25th of the month. If I want to change the banking information that CoPower debits, I will submit a new Direct
Debit Authorization form by the 25th of the month. In the event a debit is made to my account in error, I authorize CoPower to make a correcting
entry to my account. CoPower will notify me of payments returned for insufficient funds or closed accounts, and repayment instructions. Please
attach a copy of a voided check.
Employer Signature
My signature authorizes CoPower to administer my Anthem ancillary benefits. I understand that Anthem medical and Anthem ancillary group
numbers and bills will be received separately if the group is enrolled in both.
Signature of Company Officer:
Date:
Name (print):
Title (print):
CoPower provides third-party administrative services in connection with Anthem Blue Cross products. Dental HMO products underwritten by Anthem Blue Cross; dental PPO,
vision and life products underwritten by Anthem Blue Cross Life and Health Insurance Company. Anthem Blue Cross is the trade name of Blue Cross of California. Anthem
Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. ANTHEM is a registered trademark of
Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association.
CPF-056 8/14