Individual Emerald Plan Enrollment - Vision Plan of America

Individual Emerald Plan Enrollment

Name *

Email Address

Address *

Apt:

City

State

Zip

Phone *

Birthdate

Language Preference

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 dental offices

Desired Plan

Individual Emerald

Payment Information

I Wish To Pay My Premium Monthly

Member ($24.00)
Member + 1 Dependent ($42.00)
Family ($59.00)

A one-time non-refundable $16.00 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 12 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