Fill - Free fillable Form 01: AVESIS ADVANTAGE VISION CARE EMPLOYEE ENROLLMENT (Presbyterian College) PDF form

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

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

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)

PLEASE PRINT LEGIBLY

01/12 - R03

FIRST LAST

Presbyterian College

20790-1060

923

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Form 01: AVESIS ADVANTAGE VISION CARE EMPLOYEE ENROLLMENT (Presbyterian College)

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