Copower forms 2025

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4 out of 5

48 votes

The document is a CoPower ONE Employee Enrollment/Change Form that must be completed by a group administrator and submitted to CoPower within 30 days of any changes. It collects employer and member information, including personal details, plan selections, reasons for enrollment or change, and dependent information. The form also outlines eligibility criteria for dependents and provides contact information for CoPower.

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Click ‘Get Form’ to open the CoPower ONE Employee Enrollment/Change Form in the editor.
Begin by filling out the Employer Information section. Enter the Group Name, CoPower ID#, Contact Person, Contact E-mail, and Contact Phone Number.
Next, move to the Member Information section. Fill in your Last Name, First Name, Social Security Number, Street Address, City, State, Zip Code, and Phone Number.
Select your CoPower ONE Plan by checking either Good, Better, or Best. If applicable, choose your Dental Plan (PPO or HMO) and provide the Date of Hire and Date of Birth.
Indicate the Effective Date for enrollment and complete any additional fields regarding dental office information if enrolling in HMO.
In the Dependents to be Enrolled or Terminated section, provide details for each dependent including their names, dates of birth, and whether they are being enrolled or terminated.
Finally, sign and date the form at the bottom before submitting it via email or fax within 30 days of any changes.

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Versions	Form popularity	Fillable & printable
2021	4.8 Satisfied (70 Votes)
2018	4.3 Satisfied (40 Votes)
2013	4 Satisfied (48 Votes)

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