Group Employee Enrollment - Vision Plan of America

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Employee Enrollment Form
For HMO Vision Benefits

Name *
Email Address
Address *
City
State
Zip
Phone *
Birthdate
Gender	Male Female
Employer (Group) Name
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 Code Number	Find a provider now

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.

CIA is an affiliate of
Vision Plan of America.

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