TO BE COMPLETED BY THE EMPLOYEE
Employee Last Name Employee First Name MI
Date of Birth Social Security Number Sex
Street Address Apartment No.
City State Zip Code
TO BE COMPLETED BY THE EMPLOYER
New Enrollment Add
Dependent(s)
Change
Address Phone
Name COBRA
Cancel Coverage
Policy Holder
Dependent(s)
Reason for Change Employment Status
Qualifying Event:
(PLEASE STATE) ___________________________________________
Requested Effective Date Date of Employment
AVESIS ADVANTAGE VISION CARE EMPLOYEE ENROLLMENT FORM
Underwritten by Fidelity Security Life Insurance Company Kansas City, Missouri Policy No. VC-16/VC-23
MACY C. O’BRIEN SCHOOL DISTRICT #90 & PINAL COUNTY SPECIAL EDUCATION
12345-1234
01
900
I authorize deductions from my earnings at the required contributions towards the cost of the coverage.
Signature Date
A-00713 M-9059/M-9069/M-9086
Dependent Name Date of Birth
Spouse /
Domestic Partner
Child
Child
Child
Child
Child
Child
Male Female
Do you wish to cover your eligible dependents? Yes No
If yes, complete the following:
I would like to cover additional eligible dependents
(PLEASE LIST ON A SECOND ENROLLMENT FORM)
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PLEASE PRINT LEGIBLY
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01/12 - R03
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FIRST LAST
Presbyterian College
20790-1060
923
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