E-mail Forms

E-mail forms to yourself or others by selecting the checkbox right next to each form. Click the 'E-mail Forms' button at either the top or bottom of this page once you have selected your items. A new pop-up window will display, allowing you to specify recipients.

CoPower ONE

For Employers

CoPower ONE Employer Application

CoPower ONE Census Enrollment Form

Member Termination Form

Employer COBRA Designation Form

Employer AutoPay Authorization Form

Employer One-Time Direct Debit Authorization Form

Employer Information Change Form

Group Cancellation Form

Delta Dental Employer HIPAA BAA Agreement

For Employees

CoPower ONE Enrollment/Change Form
CoPower ONE Enrollment/Change Form (Spanish)

CoPower ONE Waiver Form

Delta Dental Claim Form

UNUM Member Voluntary Life Application

UNUM Evidence of Insurability Form

UNUM Change Request Form - Voluntary Life

UNUM Member Beneficiary Designation Form

UNUM Life & AD&D Claim Form

UNUM Notification of Conversion Form

UNUM Portability Form

VSP Out-of-Network Reimbursement Form

For Brokers/Sales

Broker Information Verification Form

Broker-Agency Direct Deposit Authorization Form

W-9 Form

CoPower OPTIONS

For Employers

CoPower OPTIONS Employer Application

CoPower OPTIONS Census Enrollment Form - Dental

CoPower OPTIONS Census Enrollment Form - Vision/Basic Life

Member Termination Form

Employer COBRA Designation Form

Employer AutoPay Authorization Form

Employer One-Time Direct Debit Authorization Form

Employer Information Change Form

Group Cancellation Form

Delta Dental Employer HIPAA BAA Agreement

For Employees

Member Enrollment/Change Form - Dental Member Enrollment/Change Form - Dental (Spanish)

Waiver Form - Dental

Member Enrollment/Change Form - Vision Member Enrollment/Change Form - Vision (Spanish)

Waiver Form - Vision

Member Enrollment/Change Form - Basic Life

Delta Dental Claim Form

Transamerica Beneficary Change Form

Transamerica Member Basic Life (Simplified) Enrollment Form

Transamerica Member Basic Life Enrollment Form

UNUM Beneficiary Designation Form

UNUM Employee Voluntary Life Application

UNUM Evidence of Insurability Form

UNUM Life & AD&D Claim Form

UNUM Notification of Conversion Form

UNUM Portability Form

UNUM Change Request Form - Voluntary Life

VSP Out-of-Network Reimbursement Form

For Brokers/Sales

Broker Information Verification Form

Broker-Agency Direct Deposit Authorization Form

W-9 Form