Employee Enrollment/Change Form – All Plans
To be reviewed and submitted by group administrator. Completed forms should be sent to CoPower within 30 days of change. Missing
information could delay processing.
Employer Information
Group Name:
CoPower ID#:
Contact Person:
Contact E-mail:
Contact Phone Number:
Member Information
Last Name, First Name:
Social Security Number:
Male
Date of Birth:
Female
Street Address:
Date of Hire:
Phone Number:
Dental
Delta:
MetLife:
Anthem:
PPO
PPO
PPO
HMO
HMO
HMO
HMO Dental Office Name:
Premier
Plan:
Vision
Anthem
VSP
Plan:
HMO Dental Office City:
City:
State:
Effective Date (1st of the month
only):
Bundled Plans
CoPower ONE:
PPO
HMO
CoPower SUITE:
PPO
HMO
Life
Unum Life
Anthem Life
Unum Vol. Life
Anthem Dep. Life
Unum LTD
Zip Code:
Landmark
Chiro
Chiro + Acu
Estimated Annual Salary (LTD
only; round up to hundred):
HMO Dental Office ID#:
Reason for Enrollment or Change (Check one)
New Hire (Effective 1st of the month following eligibility period)
Rehire
Group Open Enrollment*
Part-time to Full-time
Hire date:
New Group Enrollment
Full-time date:
Loss of Coverage
(Required: Proof of loss - a letter from the carrier or employer.)
Dependent Change
Reason:
Qualifying event date:
Fed-COBRA Enrollment
Qualifying event date:
Name or Social Security Number Change
Previous name or SSN:
Member Address Change
Other:
*Please review group plan contract to verify that open enrollment is available.
Dependents to be Enrolled or Terminated
Spouse/Domestic Partner’s Last Name, First Name:
Enroll
Child’s Last Name, First Name:
Child’s Last Name, First Name:
Date of Birth:
Dependent child is
disabled.**
Male
Date of Birth:
Dependent child is
disabled.**
Date of Birth:
Dependent child is
disabled.**
Female
Terminate
Child’s Last Name, First Name:
Enroll
Male
Terminate
Male
Spouse
Domestic Partner
Female
Terminate
Enroll
Date of Birth:
Female
Terminate
Enroll
Male
Female
**Check only if enrolling a child age 26 & over and if disability occurred prior to limit age. Orthodontic limitations may apply.
Member Signature
Date:
CoPower • 1600 W. Hillsdale Blvd., San Mateo, CA 94402 • Phone: 888.920.2322 • Fax: 650.348.1149 • E-mail: requests@copower.com
CPF-058 5/15