Fillable Get File GroupId 4202574 Filename Active 20 20VSP 20Premier 20Enrollment 20Form (California Maritime Academy)

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Get File GroupId 4202574 Filename Active 20 20VSP 20Premier 20Enrollment 20Form (California Maritime Academy)

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The Get File GroupId 4202574 Filename Active 20 20VSP 20Premier 20Enrollment 20Form (California Maritime Academy) form is 1 page long and contains:

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  • 6 check-boxes
  • 42 other fields

Country of origin: US
File type: PDF

U.S.A. forms for California Maritime Academy

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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.)
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 enrollment in the Premier Plan is effective with the first Premier Plan deduction from
my payroll check. Uncollected premiums will result in the termination of my VSP benefit unless other payment arrangements are made with VSP.
Enrollee Signature __________________________________________________________________ Date _____________
By signing above, I understand that I am enrolling in Premier for a minimum of a 12 month periodBOE*DFSUJGZUIBUUIF
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VSP
®
Vision Care1SFNJFS Enrollment Form
The California State University
Active
Sign up for VSP Premier Benefits
Enrollee Information
Full SSN _________________ 0GGJDJBM$BNQVT/BNF@@@@@____@@@@@@@@@@@@@@@@
Date of Birth _ _ ________/ ________ / __________ (FOEFS@@@__@@@@__@@@__@@@@
Legal First Name _______________________________________________________
Legal Last Name _______________________________________________________
Home Address ________________________________________________________
City __________________________________ State ______ Zip Code ___________
Email Address ________________________________________________________
Phone Number ________________________________________________________
Your VSP Premier Coverage (Choose one.)
Member Only. . . . ...................$4.33 Monthly
Member + One . . . ..................$16.13 Monthly
Member + Family . . . . . . . . . . . . . . . . . . . $30.52 Monthly
©2017 Vision Service Plan. All rights reserved.
VSP and VSP Vision care for life are trademarks of Vision Service Plan. 10767
Enrollment
Up to 60 days after your
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VSP Client Number
30077022
Questions?
Call VSP at 800.400.4569
or visit
csuactives.vspforme.com
ENROLLING
IN VSP IS EASY
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Pr
remier Dependent Requirement:
Eligible Xependents not included with Premier
enrollment will not be able to seek services under the Basic Plan"
Maximum Age Limits: Child Age: 26"Dependent would be eligible until
the last day of their birth month at the age listed above.
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Get File GroupId 4202574 Filename Active 20 20VSP 20Premier 20Enrollment 20Form (California Maritime Academy)

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Completed 19 July 2020

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