Vsp Enrollment Form

Enrollment Form

Name of Group (Employer)

Employee Name: _______________________________________

last name, first name, middle initial

Employee Social Security Number: ________________________

Employee Date of Birth: _________________________________

Type of coverage selected:

_____Employee only

_____Employee plus one dependent

_____Employee plus children

_____Employee plus family

_____Waive Coverage

___________________________

Employee Signature

Please return this form to your benefits administrator.

Clients: This form provided for your internal use only. Please do not return to VSP.

Thank you.

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Parent category: Business