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Employee Enrollment Form
For HMO Vision 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
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Desired Plan

HMO A (12/12/12/12)
HMO B (12/12/24/12)
HMO C (12/24/24/24)
M-Plus (co pay plan)
 

 

* 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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