CoPower ONE Employer Application
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- Aron Burns
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1 CoPower ONE Employer Application Group Information Street Address: DBA: State: Zip: What is your communication preference? Mail Fax Billing Address (if different): State: Zip: Employer is a: Partnership Corporation Sole Proprietorship Public Agency Other (Please Explain): Type of Business: Tax ID #: Requested Effective Date Business Established: Contact Name: SIC Code (required): HRAnswerLink Enrollment (Free Online HR Support): Yes No Title: Phone: Fax: Group Eligibility Information Total # of Employees: Total # of Eligible Employees: Total # of Enrolling Employees: Prior Dental Carrier: Dental Cancel 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) Employer Contribution: Employee = (minimum 75%) Dependent = (minimum 0%) 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. CoPower ONE Package Information Dual choice dental option (PPO/HMO), Enhanced Life Option and LTD are available to groups with 10+ enrolling employees. CoPower ONE: Good CoPower ONE: Better CoPower ONE: Best Unum Enhanced Life Option: $50k $100k $150k Select one to replace the standard life amount. Additional premium rates apply. Unum Voluntary Option: Yes No If yes, please check both Group Lifestyle Protection Benefits boxes on page 4. Each member or spouse applying must submit the Unum Voluntary Life Application. 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: Yes No If Yes, choose benefit: $300 $500 $1,000 In order to maintain enrollment in the plans included in the CoPower ONE program, you must continue coverage in all three 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. Page 1 of 5
2 Payment Invoices How would you like to receive invoices? Mail Both If /Both selected please complete the following: Contact Name Title address 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 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: Name (print): Producer Statement (must be completed for commissions) Producer s Signature: Producer s Name (print): Federal Tax ID or SSN: Address: Title (print): Producer Statement (must be completed for commissions) Producer s Signature: Producer s Name (print): Federal Tax ID or SSN: Address: 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 2 of 5
3 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: 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 3 of 5
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