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Employee Enrollment Form
For HMO Vision & Dental Benefits

Name *
Email Address
Address *
City
State
Zip
Phone *
Work Phone
Birthdate
Gender Male Female
Employer
Group #
Status Active Retiree
Coverage Effective Date
Covered Dependents - List Eligible Dependents (Same Residence)
Spouse
Birthdate
Gender Male Female
Student Yes No
Child 1
Birthdate
Gender Male Female
Student Yes No
Child2
Birthdate
Gender Male Female
Student Yes No
Child 3
Birthdate
Gender Male Female
Student Yes No
Optometrist Code Number
Find a provider now
Dentist Code Number
(For Best Choice, Diamond, and Platinum Plans)


List of participating Northern California dental offices
List of participating Southern California dental offices

Desired Plan

Best Choice (M-Plus + 460)
Diamond (M-Plus + 495)
Platinum (B-2 + 495)
 

 

* Required Fields

 
I authorize my employer to deduct from my wages the required premium, if any, for myself and/or listed eligible dependents. This agreement shall remain in effect for a term of 12 -or- 24 months to coincide with the group application and agreement based upon plan selection, or until my employment is terminated.
 

 


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