Individual Best Choice Plan Enrollment

Individual Best Choice Plan Enrollment

Name *

Email Address

Address *

Apt:

City

State

Zip

Phone *

Birthdate

Employer
(if applicable)

Covered Dependents - List Eligible Dependents (Same Residence)

Spouse

Birthdate

Child 1

Birthdate

Child2

Birthdate

Child 3

Birthdate

Optometrist Code Number *

Dentist Code Number *

List of participating Northern California dental offices
List of participating Southern California dental offices

Desired Plan

Individual Best Choice

Payment Information

I Wish To Pay My Annual Premium In Full

Individual ($149.00)
Member + 1 Dependent ($215.00)
Family ($255.00)

A one-time non-refundable $15.00 enrollment fee is included.

I Wish To Pay My Premium Monthly

Individual ($12.0)
Member + 1 Dependent ($18.00)
Family ($22.00)

A one-time non-refundable $15.00 enrollment fee will be added to your first month's fees.

I wish to enroll in the Vision Plan of America Program. I understand that all necessary services will be provided as described in the Evidence of Coverage and this contract is for a minimum of 24 months.

VPA Agency Code Number
(Become an agent)

Promo Code

Once this information is received by The Plan, a Plan representative will telephone you for your social security number and a credit card or other method of payment.

All enrollment information received prior to the 20th of the month will be effective on the first of the following month.

* Required Fields