VISION BENEFITS OF AMERICA VBA# 3286 SUBGROUP#______
ENROLLMENT FORM
COVERAGE EFFECTIVE DATE _________/___________/___________
INSTRUCTIONS FOR EMPLOYEE:
1. COMPLETE SECTION BELOW AND SIGN.
2. RETURN COMPLETED FORM TO YOUR BENEFITS OFFICE.
EMPLOYEE SOCIAL SECURITY NUMBER ________________________________________________
EMPLOYEE NAME________________________________________ BIRTHDATE ____|______|______
ADDRESS __________________________________________________________________________
CITY ___________________________ STATE____________ZIP CODE ___________-___________
PLEASE LIST ALL FAMILY MEMBERS TO BE COVERED:
FIRST NAME MIDDLE INITIAL LAST NAME BIRTHDATE
SPOUSE _____________________________________________________________|______|______
CHILD _______________________________________________________________|______|______
CHILD _______________________________________________________________|______|______
CHILD________________________________________________________________|______|______
CHILD________________________________________________________________|______|______
STUDENT INFORMATION (COMPLETE FOR DEPENDENTS WHO ARE ENROLLED AS FULL-TIME COLLEGE STUDENTS.)
STUDENTS NAME NAME OF SCHOOL OR UNIVERSITY
_____________________________________________________________________|_______|_____
_____________________________________________________________________|_______|_____
ANY HANDICAPPED CHILD COVERED ON MEDICAL?
CHILD NAME
______________________________________________________________________________________|__________|______
EMPLOYEE SIGNATURE _______________________________________ DATE ______/_____/_____
