Vsp Client Enrollment Form

VISION SERVICE PLAN

MEMBERSHIP ENROLLMENT FORM

Cal-Pac Annual Conference of the UMC 12327445

Effective Date

Social Security No.

Last Name / First Name / MI

Date of Birth

Home Address:

Name of Church you work for:

Do you have dependent children - Y

Does your spouse have coverage with VSP?

Are you enrolling your dependents in the VSP Plan? Y

If Yes, who is covered?

Coverage Level

Employee Only

$6.00

Employee + Spouse

$12.00

Employee + Child(en)

$12.00

Employee + Family

$18.00

PLEASE LIST ALL OF YOUR DEPENDENTS THAT WILL BE ENROLLED IN THE PROGRAM

Last Name / First Name / MI

Social Security No.

Date of Birth

Please return to the Cal-Pac Health Benefits Dept: Fax 626-577-1620

Signature_______________________________________________ Date_______________________

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