Employer Application (Delta Dental, VSP and UNUM Life)

Employer Information
Company Name: / DBA:
Address and Suite #:
City: / State: / Zip:
Billing Address (if different):
City: / State: / Zip:
Contact Name: / Title:
E-mail: / Phone: / Fax:
Date Business Established: / Tax ID #:
Partnership Corporation Sole Proprietorship Public Agency Other: / SIC Code (required):
COBRA Status: Federal COBRA (Year effective ) Cal-COBRA (Year effective )
Are Domestic Partners being allowed to enroll in the plan? Yes No
Are the children of Domestic Partners eligible to enroll in the plan? Yes No / What is your communication preference?
Mail E-mail Fax
Coverage Applying For: (Check all that apply)
Dental Vision Life / Eligibility begins on the first of the month following:
Date of Hire 1 Month 2 Months 3 Months 6 Months Other
Is the waiting period waived for initial enrollment? Yes No
DELTA DENTAL
Dental Eligibility Information (All sections must be completed)
Requested Effective Date: / Prior Carrier: / Cancel Date:
Total Number of Employees: / Total Number of Eligible Employees: / Total Number of Enrolling Employees:
Delta Dental Choice, Delta Dental Classic, DeltaCare Plan Selection
Choice (Non-Voluntary); 5-99 / Classic (Non-Voluntary); 5-49 / DeltaCare; 5-99
Premier Plans
Choice Premier 1000
Choice Premier 1500
Choice Premier 2000
PPO Plans
Choice PPO 1000
Choice PPO 1500
Choice PPO 2000
Optional Child Orthodontia
Yes No
Orthodontia is available to groups with 10 or more enrolling employees.
Employer Contribution
Employee: 100% (required)
Dependent: (minimum 50%) / PPO Plans
Classic PPO A
Classic PPO B (PPO+Premier)
Classic PPO C (PPO+Premier) / PPO Max
1000
1500
2000 / DeltaCare Choice HMO
Plan 10B, Non-Voluntary
Employer Contribution
Employee: 100% (required)
Dependent: (minimum 50%)
DeltaCare Classic HMO
Plan 10A Plan 11A
Plan 12A Plan 15B
Employer Contribution Options
Option A, Non-Voluntary
Employee: (minimum 100%)
Dependent: (minimum 100%)
Option B, Non-Voluntary for Employee
Employee: (minimum 75%)
Dependent: (minimum 0%)
Option C, Voluntary*
Employee: (0% to 74%)
Dependent: (0% to 74%
*Available for Dual Choice with Vol PPO only; 100% employee paid.
D&P Max Waiver
Yes No
Optional Child Orthodontia
Yes No
Orthodontia is available to groups with 10 or more enrolling employees.
Employer Contribution
Employee: (minimum 75%)
Dependent: (minimum 0%)
Classic (Voluntary); 5-99
Voluntary PPO
Waive waiting period
Yes No
Only available with prior comprehensive dental; for initial enrollees only.
Optional Child Orthodontia
Yes No
Orthodontia is available to groups with 25 or more enrolling employees.
Employer Contribution
Employee: (0% to 74%)
Dependent: (0% to 74%
Delta Dental Options Plan Selection (50-99 Enrolling Employees)
Options Standard Plans (Non-Voluntary); 50-99 / Optional Plan Features
PPO Plans
Options PPO 1(PPO+Premier)
Options PPO 2 (PPO+Premier)
Options PPO 3 (PPO+Premier) / PPO Max
1000
1500
2000 / Choose only those optional benefits you wish to elect. If standard benefit is desired, please leave blank.
STANDARD / OPTIONS
Deductible / $50 individual/$150 family
(PPO3 $40/$120 in network; $50/$150 out) / $25/$75
(PPO3 $0/$0 in network;
$25/$75 out)
Orthodontia / Not covered / Child only Adult & Child
Ortho Lifetime Max / Choose one if ortho selected / $1,000 $1,500
Endo/Perio / Covered as Basic Service / Covered as Major Service
D&P Max Waiver / Not Covered / D&P Max Waiver
Employer Contribution
Employee: (minimum 75%)
Dependent: (minimum 0%)
VISION SERVICE PLAN
Vision Eligibility Information (All sections must be completed)
Requested Effective Date: / Prior Carrier: / Cancel Date:
Total Number of Employees: / Total Number of Eligible Employees: / Total Number of Enrolling Employees:
Vision Service Plan Selection (2+ Enrolling Employees)
Signature Plans / Choice Plans
Plan A $25 / Plan B $25
Plan B $10/Voluntary / Plan C $10
Plan C $10/Voluntary / Plan A $20
Plan A $25/$25
Plan B $20/$20 Voluntary
Vision Plan Employer Contribution
Employee: (minimum contribution is 100% for all plans except the voluntary plans)
Dependent: (minimum 0%)
A $15 administrative fee is charged each month to all VSP groups.
New groups with 2 to 4 employees are charged a discounted administrative fee of $10 per month, guaranteed for one year.
UNUM
Unum Life and AD&D Eligibility Information (All sections must be completed)
Requested Effective Date: / Prior Carrier: / Cancel Date:
Total Number of Employees: / Total Number of Eligible Employees: / Total Number of Enrolling Employees:
Unum Life and AD&D Plan Selection
Basic Life and AD&D / Voluntary Life & AD&D*
Less than 10 Employees
$10,000 Flat Benefit
$15,000 Flat Benefit
$20,000 Flat Benefit
$25,000 Flat Benefit / More than 10 Employees
$10,000 Flat Benefit
$15,000 Flat Benefit
$25,000 Flat Benefit
$50,000 Flat Benefit / Voluntary Life and AD&D (employee paid)
Employee
Spouse (must select employee coverage)
Children (must select employee and spouse coverage)
*UNUM Voluntary Buy-Up Option: Yes No / If yes, please check the Group Lifestyle Protection Benefits boxes on page 5.
Payment
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 Ban
:
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.
Signatures
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 to be paid) / Producer Statement
(must be completed for commissions to be paid)
Date: / Date:
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: / State: / Zip:
Telephone: Fax: / Telephone: Fax:
E-mail: / E-mail:
Make commissions payable to: Producer Agency / Make commissions payable to: Producer Agency
Multiple producer split: : Yes No / Multiple producer split: : Yes No
Percentage of split: % / Percentage of split: %

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

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)

Page 1 of 5 CPF-020 01/11