Fillable VSP Vision Cancellation Request Form2015 (Southwest Tennessee Community College)

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VSP Vision Cancellation Request Form2015 (Southwest Tennessee Community College)

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VSP VISION CANCELLATION REQUEST FORM
(Please email completed form to lperry@benalytics.com or fax to (770) 420-0535)
NAME: ________________________________________________________________
LAST 4 DIGITS OF SSN: __________________________________________________
INSTITUTION: ___________________________________________________________
EMAIL ADDRESS: _______________________________________________________
Please cancel my VSP Vision Coverage for the 2015 plan year.
My signature below authorizes Tennessee Board of Regents to cancel my
VSP Vision coverage and corresponding payroll deductions effective
December 31, 2014.
I understand I cannot re-enroll in VSP Vision
coverage for 12 months and re-enrollment must occur during an open
enrollment period.
__________________________________________
_______ ___________
Employee Signature Date
Southwest Tennessee Community College
09/30/2014
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VSP Vision Cancellation Request Form2015 (Southwest Tennessee Community College)

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Completed 23 July 2020

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