Chaffey College
Human Resources
DC VSP 0411
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VISION SERVICE PLAN ENROLLMENT/CHANGE FORM
It is the employee's responsibility to notify Human Resources of any family status change
(i.e., marriage, divorce, new dependents, etc.) within 30 days of the event.
Employer Section: OFFICE USE ONLY
Event
date:
Effective
date:
Please check one:
New enrollment (hire date is the event date):
Group Name:
Chaffey College
Change of Coverage (enter date of change)
Group Number:
00809401
Marriage Loss of dependent status
Divorce Death:_________________
Add/Delete Dep. Other:__________________
Active Division:
20
COBRA enrollment ……..Term date:
COBRA:
67
Employee Information (please print or type):
Soc. Sec #:
Date of Birth:
Last Name:
First Name:
MI:
Address:
Sex : M F
Marital Status:
Married
Single
PLEASE LIST ALL OF YOUR DEPENDENTS:
Action
Last Name First Name M.I. Date of Birth Sex Add Delete SSN #
1.)Spouse
2.) Children (include surname if different )
3.)
4.)
5.)
6.)
Employee Signature Date
