Individual VIP Premier Plan Signup - Vision Plan of America

Individual VIP Premier 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 *

Desired Plan

Individual VIP Premier

* Payment Information

I Wish To Pay My Annual Premium In Full

Individual ($129.00)
Member + 1 Dependent ($234.00)
Family ($327.00)

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

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. Once the benefits have been utilized, the member must remain enrolled to the end of the contract.

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