Group Vision Plan Signup - Vision Plan of America

Group Vision Plan Application
(HMO A, HMO B, HMO C, M-Plus)

Employer Information
Company/Organization Name *
Street Address *
City
State
Zip
Billing Address
City
State
Zip

Your Email Address

Desired Effective Date

Name & Title of Person to Whom Billing is Directed *
Phone Number *
Type of Business
Has Employer Filed for Bankruptcy in the Past Seven Years?	Yes No

Select One:	Employer Paid: % Voluntary * * For voluntary plans, the individual employees need to fill out and sign an enrollment form, which can be found here. Please fax the completed enrollment form to 213-384-0084
Remarks

Plan:	A B C M-Plus

Deductible

Employee	No. Enrolled: x Rate $ = $

Employee Plus One Dependent	No. Enrolled: x Rate $ = $

Employee Plus Two or More Dependents	No. Enrolled: x Rate $ = $

Monthly Administration Fee	$10.00

Total	$ (First Month's Remittance)


Please make all checks payable to: Vision Plan of America and mail to: Vision Plan of America 3255 Wilshire Blvd., Suite 1610 Los Angeles, CA 90010
Agent of Record

Name
VPA Code

	* Required Fields
The benefits for which Subscribers and enrolled dependents are eligible under this Group Subscriber Agreement are described in Combined Evidence of Coverage/Disclosure Form ("Evidence of Coverage"), which is attached to and becomes a part of the Group Subscriber Agreement. The Evidence of Coverage includes important terms and conditions of the Group Subscriber Agreement and should be read carefully. I hereby request the coverage indicated above. This contract is covering all "A" plans for a period of twelve (12) months, and covering all "B" and "C" plans for a period of twenty-four (24) months, and will renew automatically and is subject to the terms and conditions as outlined in the Group Subscriber Agreement.