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Employer Paid Group Vision & Dental Plan Application
(Group Best Choice, Diamond and Platinum)
 Voluntary groups need to fill out and sign the downloadable PDF forms.

Company/Organization Name *
Tax ID
Your Email Address
Desired Effective Date
Street Address *
City
State
Zip
Name & Title of Person to Whom Billing is Directed *
Phone Number *
Fax
Email
Corporation Status
Type of Business
SIC Code
Corporation Type
(Corporation, Sole Proprietorship, Partnership, Other - Please specify)
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
Requested waiting period for enrollment of future employees. Eligibility date will be the first day of the month following the waiting period.
Waiting Period for Enrollment

30 Days
60 Days
90 Days
Other

Employer Eligibility: Eligible Employees shall be active, full time employees who work at least 30 hours per week.
Number of Eligible Full Time Employees
Number of Eligible Others
(Please explain)
Plan: Best Choice
Diamond
Platinum
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 $15.00
Total $
   
Agent of Record
Name
VPA Code
 

 

* Required Fields

 
Benefits become effective after Vision Plan of America receives a signed contract (which will be mailed to you within 3 business days) and first month's premium.
 

 



CIA is an affiliate of
Vision Plan of America.

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