retirement
VSP Client Number
300
Questions?
Call VSP at 800.400.4569 or
visit
csuretirees.vspforme.com
ENROLLING
IN VSP IS EASY
Send this completed form to:
VSP TPA Client Services
P.O. BOX 997100
Sacramento, CA 95899
Add
Family Member Name
(Only list dependents if you didn’t select Member Only.)
Date of Birth
(Month/Day/Year)
Gender
(M/F)
Relationship to Member
(Spouse/Domestic Partner, Child, etc.)
VSP
®
Vision Care Enrollment Form
Retirees
Sign up for VSP.
Enrollee Information
________________________
Date of Birth ________ / ______ / ________
Legal First Name ___________________________________________________
Legal Last Name ___________________________________________________
Home Address ____________________________________________________
City ________________________________ State ______ Zip Code _________
Email Address ____________________________________________________
Phone Number ____________________________________________________
Your VSP Coverage (Choose one.)
Member Only. . . . ...................$ Monthly
Member + One .................... .$ Monthly
Member + Family . . . . . . . . . . . . . . . . . . . $ Monthly
Maximum Age Limits: Child Age: 26. Dependent would be eligible until
the last day of their birth month at the age listed above.
©2017 Vision Service Plan. All rights reserved.
VSP and VSP Vision care for life are trademarks of Vision Service Plan. 10767
Enrollment
Up to 0 days after your
Member Only. . . . . . . . . . . . . . . . . . . . . . . $1 . Monthly
Member + One .....................$2
. 3 Monthly
Member + Family . . . . . . . . . . . . . . . . . . . $ .5 Monthly
The California State University
________________________
Plan
Plan
Gender
Please read before signing. By accepting the enrollment terms, I agree that all information is true and accurate. I understand that I am enrolling in
this voluntary plan as described in the benefit document for a minimum twelve (12) month period. I understand that upon completion of my twelve
(12) months, I will not be eligible to make changes to my plan until the next open enrollment period. I understand my VSP plan will automatically
renew unless I specifically elect not to renew. I understand that my VSP premiums will automatically be deducted from my retirement check.
Uncollected premiums will result in the termination of my VSP benefit unless other payment arrangements are made with VSP.
Signature __________________________________________________________________ Date _____________
By signing above, I understand that I am enrolling for a minimum of a 12 month period.
