Fillable Vision Plan Enrollment Form Your Location: Roger Williams (Roger Williams University)

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Vision Plan Enrollment Form Your Location: Roger Williams (Roger Williams University)

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Vision Plan Enrollment Form
Revised 11/1/2017
Your Location: Roger Williams University Roger Williams University School of Law
INSTRUCTIONS: Please complete all of your personal and dependent information below. Select the plan and the type of
coverage you wish to enroll in, sign and date the form, and return to the Department of Human Resources.
Employee Name: __________________________________________________ Date of Birth: _______________
Last First M.I. (mm/dd/yyyy)
Home Address: ____________________________________________________________________________
City State ZIP Code
SSN: ______ - _____ - ______ Email Address: _______________________________ Phone: ( ___ ) ____ - _____
Gender: male female Date of Hire: _________________ Effective Date of Coverage: _ _____________
(mm/dd/yyyy)
(mm/dd/yyyy)
Type of coverage selected:
Bi-Weekly Rates
Member only
Member + 1
Member + children
Family
Base Plan (Plan B)
$ 3.04
$ 4.86
$ 4.97
$ 8.01
Premium Plan (Plan C)
$ 4.52
$ 7.23
$ 7.38
$11.90
* Dependent Relationship: S=spouse, C=child, H=handicapped child, T=student
Dependent last name Dependent first name Gender * Dependent Relationship
Date of birth
mm/dd/yyyy
S C H T
/ /
S C H T
/ /
S C H T
/ /
S C H T
/ /
S C H T
/ /
S C H T
/ /
Employee Signature: ______________________________________ Date: ______________
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Vision Plan Enrollment Form Your Location: Roger Williams (Roger Williams University)

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Completed 1 February 2021

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