Group Application (Delta Dental, VSP and Unum Life & LTD)

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1 Group Application (Delta Dental, VSP and Unum Life & LTD) Group Information Company Name: DBA: Street Address: City: State: Zip: Billing Address (if different): City: State: Zip: Employer is: Partnership Corporation Sole Proprietorship Public Agency Date Business Established: Other (Please Explain): SIC Code (required): Type of Business: Tax ID #: Contact Name: Phone: Fax: What is your communication preference? Mail Fax Title: Coverage Applying For: (Check all that apply) Dental Vision Life LTD Requested Effective Date: Group Eligibility Information Total Number of Employees: Total Number of Eligible Employees: Total Number of Enrolling Employees: Is the waiting period waived for initial enrollments? Yes No Eligibility begins on the first of the month following: Date of Hire 1 Mo. 2 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) Does company have a pre-tax Sec. 125 or POP plan? Yes No Is your group currently subject to Cal-COBRA? Yes No (Employed 2-19 eligible employees on at least 50% of its working days in the previous calendar year)* Is your group currently subject to COBRA? Yes No (Employed 20+ eligible employees on at least 50% of its working days in the previous calendar year)* Domestic Partners allowed to enroll? Yes No Children of Domestic Partners eligible to enroll? Yes No *Visit for more COBRA eligibility information. Vision Service Plan Prior Carrier: Cancel Date: Total Number of Enrolling Employees: Vision Service Plan Selection (2+ Enrolling Employees) Choice Plans Signature Plans Plan A $20 Plan A $25/$25 Plan B $20/$20 Voluntary Plan B $25 $150/$150 Plan C $25 $150/$150 Plan C $25 Voluntary $150/$150 Plan A $25 Plan B $25 Employee: Vision Plan (100% for all plans except the voluntary plans) 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. Page 1 of 6 CPF /13

2 Delta Dental Prior Carrier: Cancel Date: Total Number of Enrolling Employees: 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. PPO Plans Classic PPO A Classic PPO B-12 Classic PPO C (PPO+Premier) PPO Max D&P Max Waiver Yes No Optional Child Orthodontia Yes No Orthodontia is available to groups with 10 or more enrolling employees. Employee: (minimum 75%) DeltaCare USA Choice Plan 10B, Non-Voluntary Employee: 100% (required) Dependent: (minimum 50%) DeltaCare USA Classic Plan 10A Plan 12A Plan 11A Plan 15B Options Option A, Non-Voluntary Employee: (minimum 100%) Dependent: (minimum 100%) Classic (Voluntary); 5-99 Employee: 100% (required) Dependent: (minimum 50%) Voluntary PPO Option B, Non-Voluntary for Employee Waive waiting period Yes No Employee: (minimum 75%) Only available with prior comprehensive dental; for initial enrollees only. Optional Child Orthodontia Yes No Option C, Voluntary* Orthodontia is available to groups with 25 or Employee: (0% to 74%) more enrolling employees. Dependent: (0% to 74%) *Available for Dual Choice with Voluntary Employee: (0% to 74%) PPO only; 100% employee paid. Dependent: (0% to 74%) Delta Dental Options Plan Selection (50-99 Enrolling Employees) Options Standard Plans (Non-Voluntary); Optional Plan Features Choose only those optional benefits you wish to elect. If standard benefit is desired, please PPO Plans PPO Max leave blank. Options PPO 1(PPO+Premier) 1000 STANDARD OPTIONS Options PPO 2 (PPO+Premier) 1500 Deductible $50 individual/$150 family $25/$75 Options PPO 3 (PPO+Premier) 2000 (PPO3 $40/$120 in network; (PPO3 $0/$0 in network; $50/$150 out) $25/$75 out of network) Orthodontia Not covered Child only Adult & Child Employee: (minimum 75%) 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 Unum Life/AD&D and LTD Prior Carrier: Cancel Date: Total Number of Enrolling Employees: Less than 10 Enrolled Employees $10,000 $15,000 $20,000 $25,000 Unum Basic Life and AD&D* Voluntary Life & AD&D* (employee paid) Unum LTD* More than 10 Enrolled Employees $10,000 $50,000 $15,000 $100,000 $20,000 $150,000 $25,000 Voluntary Life Option: Yes No Each member or spouse applying must submit the Unum Voluntary Life Application. Please sign & check both Group Lifestyle Protection Benefits boxes on page 5. Select Elimination Period: 90 day 180 day 360 day Healthcare Protect Rider: Yes No If Yes, choose benefit: $300 $500 $1,000 Please complete and sign Application For Group Insurance-LTD on page 6. Class Schedule: (3 employee min. per class Further class specifications may be provided on separate sheet) Schedule A: Same coverage Schedule B: Coverage Differs by Job Classification for all Job Classifications Class 1: Class 2: Class 3: *A $10 administrative fee is charged each month to ALL UNUM GROUPS. Page 2 of 6 CPF /13

3 Payment Invoices Would you like to receive invoices electronically? Yes No If Yes, complete the following: Contact Name Title The above information will be used to authenticate access to the invoice. You must notify CoPower if this contact or 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 25 th 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 25 th 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) Date: Producer s Signature: Producer s Name (print): Federal Tax ID or SSN: Company Name: Address: City: Producer Statement (must be completed for commissions) Date: Producer s Signature: Producer s Name (print): Federal Tax ID or SSN: Company Name: Address: City: State: Zip: State: Zip: Telephone: Fax: Telephone: Fax: 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: % Page 3 of 6 CPF /13

4 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 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 , option 3. Policyholder Representative Signature: (must be an officer of the company) Print Policyholder Representative Name: Date: Policy No: Unum Use Only Policyholder Name: Field Office Contact Name: Field Office Contact Number: Fax or to BCS: or c.exceptionrequest@unum.com 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 CA (09/08) Page 4 of 6 CPF /13

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unum APPLICATION FOR GROUP INSURANCE LTD Unum Life Insurance Company of America 2211 Congress Street Portland, Maine 04122 Name of Applicant - ---------------------------------------

6 unum APPLICATION FOR GROUP INSURANCE LTD Unum Life Insurance Company of America 2211 Congress Street Portland, Maine Name of Applicant Address: , (Street) (City) (State) (Zip) applies to the Unum Life Insurance Company of America, for: o Group Life Benefits 0 Group Cancer Benefits o Group Long Term Care Benefits 0 Group Accidental Death o Group Short Term Disability Benefits o Tax Qualified* and Dismemberment Benefits 0 Group Worksite Short Term Disability Benefits 0 Nursing Home Insurance o Group Critical Illness Benefits o Group Long Term Disability Benefits o Non-Tax Qualified** 0 Comprehensive Insurance o Group Accident Benefits Is there any group life insurance plan in force or being applied for on some or all employees? o Yes o No If yes, complete the following or list the prior carriers: Employee Class Maximum Amounts Name of Carrier Effective Dates (mmtddtyyyy) Termination Dates (mmtddfwyyj If the Insurance Company approves this application, a policy will be issued. The applicant agrees that acceptance of the policy will be an approval of the policy terms. The policy specifications will be made a part of the policy along with a copy of this form. Signed at (City and State) on, (mm/ddlyyyy) {Applicant) By: (Signature and Title) Broker Name: CoPower Administrators _ (Please Print) SS# I Tax ID# (last 4 digits): 2349 _ Broker Signature: Policy Effective Date: (mm/dd/yyyy) *The contract for Long-Term Care Insurance is intended to be a federally qualified Long-Term Care Insurance contract and may qualify for Federal and State tax benefits... The contract for Long-Term Care Insurance is not intended to be a federally qualified Long-Term Care Insurance contract. Unum is a registered trademark and marketing brand of Unum Group and its insuring subsidiaries. AE-1080-CA Page 6 of 6 CPF

Employer Application (Delta Dental, VSP, and Unum Life & LTD)

Employer Application (Delta Dental, VSP, and Unum Life & LTD) Group Information Company Name: DBA: Street Address: City: State: Zip: Billing Address (if different): City: State: Zip: Contact Name: E-mail: