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Employee Enrollment Form
For HMO Vision & Dental Benefits

Name *
Email Address
Address *
City
State
Zip
Phone *
Birthdate
Gender Male Female
Employer (Group)
Group #
Status Active Retiree
Language Preference
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 Office Number
Find a provider now
Dentist Office Number


List of participating dental offices

Desired Plan

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

 



CIA is an affiliate of
Vision Plan of America.

QualSight Preferred
LASIK Pricing