CoPower ONE Employer Application
Group Information
Company Name:
DBA:
Street Address:
City:
State:
Zip:
State:
Zip:
Billing Address (if different):
City:
Contact Name:
Title:
E-mail:
Phone:
What is your communication preference?
Mail
E-mail
Type of Business:
Employer is a:
Fax:
Fax
SIC Code (required):
Tax ID #:
Partnership
Public Agency
Corporation
Other (Please Explain):
Date Business Established:
Sole Proprietorship
Prior Dental Carrier:
None
Dental Cancel Date:
Prior Life Carrier:
None
Life Cancel Date:
Requested Effective Date:
Empower Online Administration Portal:
Yes
No
HRAnswerLink Enrollment
(Free Online HR Support):
Yes
No
Group Eligibility Information
Total # of Employees:
Total # of Eligible Employees:
Is the new hire waiting period waived for initial enrollments?
Yes
No
Total # of Enrolling Employees:
Is your group currently subject to:
1 Mo.
3 Mo.
6 Mo.
Other:
Is this group a class carve-out?
Yes
No
If yes, state the class of employees to be covered:
(For Delta Dental, employees not covered by Delta PPO plans must
enroll in DeltaCare USA plans or be left uninsured. Carve outs will be
classified as level 2 regardless of true industry SIC)
Employer Contribution:
Employee =
(minimum 75%) Dependent =
(minimum 0%)
Fed-COBRA
Cal-COBRA: Employed 2-19 eligible employees on at least 50% of
its working days in the previous calendar year*

Fed-COBRA: Employed 20+ eligible employees on at least 50% of
its working days in the previous calendar year*
Eligibility begins on the first of the month following:
Date of Hire
Cal-COBRA

Does the company have a pre-tax Sec. 125 or POP plan?
Yes
No
Do you elect Open Enrollment for your Delta Dental Plan?
(Group must have pre-tax Sec. 125 or POP plan in place)
Yes
No
Domestic Partners allowed to enroll?
Yes
No
Children of Domestic Partners eligible to enroll?
Yes
No
*Visit www.dol.gov for more COBRA eligibility information.
CoPower ONE Package Information
Dual choice dental option (PPO/HMO), Enhanced Life Option, and LTD are available to non-voluntary groups with 10+ enrolling employees.
CoPower ONE: Good (2-99)
CoPower ONE: Better Plus (5-99)
CoPower ONE: Better (5-99)
CoPower ONE: Best (5-99)
Plan Type (choose one):
PPO
HMO
Dual Choice
CoPower ONE: Voluntary PPO (5-99)
CoPower ONE: Voluntary PPO with
Orthodontia (25-99 only)
Voluntary Plans contain only Dental and Vision.
In order to maintain enrollment in the plans included in the CoPower ONE program, you must continue coverage in all lines of benefits.
Delta Dental PPO and Delta Dental PPO Plus Premier are underwritten by Delta Dental of California, VSP Choice is underwritten by Vision Service Plan, and
Unum is underwritten by Unum Life Insurance Company of America. These companies are financially responsible for their own products.
Unum Optional Benefits
Unum Enhanced Life Option:
$50k
$100k
$150k
Select one to replace the standard life amount. Add’l premium rates apply.
Unum Voluntary Option:
Yes
No
If yes, please check both Group Lifestyle Protection Benefits boxes on page 4.
Each employee or spouse applying must submit the Unum Voluntary Life App.
Unum Group Long Term Disability Option Please complete and sign Application For Group Insurance-LTD on page 5:
Select Elimination Period:
90 day
180 day
360 day
Healthcare Protect Rider:
If Yes, choose benefit:
Yes
$300
No
$500
$1,000
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CPF-021 03/15
Landmark Chiropractic & Acupuncture Optional Benefits
Cancel Date:
Chiro Only Standard $20/20
Chiro Only Standard $15/20
Chiro/ Acu Standard $20/20
Chiro/ Acu Standard $15/20
Total Number of Enrolling Employees:
Medical Carve-out? If yes, choose one:
HMO
PPO
Chiro Only Expanded $20/20
Chiro Only Expanded $15/20
Chiro/ Acu Expanded $20/20
Chiro/ Acu Expanded $15/20
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 on this document certifies that all of the information contained in this application is true and correct to the best of my knowledge.
I confirm that all enrollees are eligible employees, COBRA participants, and/or their dependents. In addition, my group complies with all the rules
and regulations as set forth by the applicable carrier(s).
Signature of Company Officer:
Date:
Name (print):
Title (print):
Producer Statement (must be completed for commissions)
Producer Statement (must be completed for commissions)
Producer’s Signature:
Producer’s Signature:
Producer’s Name (print):
Producer’s Name (print):
Federal Tax ID or SSN:
Federal Tax ID or SSN:
Company Name:
Company Name:
Address:
Address:
City:
City:
State:
Zip:
Telephone:
Date:
State:
Fax:
Telephone:
E-mail:
Zip:
Date:
Fax:
E-mail:
Make commissions payable to:
Producer
Multiple producer split:
No
Yes
Agency
Percentage of split:
%
Make commissions payable to:
Producer
Multiple producer split:
No
Yes
Agency
Percentage of split:
%
Page 2 of 5
CPF-021 03/15
GROUP MASTER APPLICATION COMPENSATION
DISCLOSURE INSERT
Your insurance or benefits advisor can offer you advice and guidance as you select the policy and provider most
appropriate for your needs. At Unum we recognize the important role these professionals play in the sale of our products
and services and offer them a variety of compensation programs. Your advisor can provide you with information about
these programs as well as those available from other providers. We support disclosure of broker compensation so that
customers can make an informed buying decision.
Unless you have agreed in writing to compensate the broker differently, Unum provides Base Commissions to all brokers in
connection with the sale of an insurance policy. Base commissions are a fixed percentage of the policy premium, and include
and one time, first year flat amount for each policy sold. Base Commissions are paid by Unum to your broker as long as
they remain the broker of record on your policy; however, in some circumstances your broker or record may continue to
receive commissions on eligible business for a fixed period of time, even after a broker of record change has occurred.
A broker may also qualify for Supplemental Commissions paid by Unum. For group insurance products, Supplemental
Commissions may be paid in an amount equal to a fixed percentage of total eligible insurance premiums. The
Supplemental Commission percentage may range from:
• For group life and disability products: 0% to 1.25% of total eligible inforce premiums paid.
• For the group critical illness product: 0% to 1.25% of total eligible inforce premiums, 0% to 11% of total eligible
new sales premiums paid and $1 per application for using our laptop enrollment system.
The exact Supplemental Commission percentage payable to any broker is based upon the total dollar amount of all group
insurance or number of policies that the broker had in force with Unum in the prior calendar year. Supplemental
Commissions may be calculated differently for other insurance products. The premium you pay is not impacted whether or
not your broker receives Supplemental Commissions.
If you would like additional information about the range of compensation programs our company offers for your group
insurance policy or any other Unum insurance product, you can find more details at www.unum.com. Should you have
other questions not addressed by the website, including the Supplemental Commission percentage applicable to your
broker, or if you want to speak to us directly about broker compensation, please call 1-800-633-7491, option 3.
Policyholder Representative Signature: ________________________________________________________
(must be an officer of the company)
Print Policyholder Representative Name: _________________________________________________________
Date: ________________________
Unum Use Only
Policy No:
Policyholder Name:
Field Office Contact Name:
Field Office Contact Number:
Fax or email to BCS: 423-763-6255 or [email protected]
Unum is providing this notice on behalf of the following insuring companies: Unum Life Insurance Company of America, First Unum Life
Insurance Company (NY), Provident Life and Accident Insurance Company and provident Life and Casualty Insurance Company (NY).
Unum is a registered trademark and marketing brand of Unum Group and its insuring subsidiaries.
1052-05-CA (09/08)
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