Vsp Enrollment Form printable pdf download

Vsp Enrollment Form

VISION SERVICE PLAN (VSP)

MEMBERSHIP ENROLLMENT FORM

COUNTY OF UNION, NJ

2017

(Please print or type)

SOCIAL SECURITY NO.

EMPLOYEE LAST NAME

FIRST NAME

MIDDLE INITIAL

DATE OF BIRTH

MO.

DAY

YEAR

EFFECTIVE DATE

DEPARTMENT

UNION AFFILIATION

Please indicate which coverage level you wish to select.

Under Chapter 78 Health Benefit Reforms, you must pay a

percentage of the single base plan. Below are the

additional contributions if you wish to add dependents:

PLEASE RETURN THIS FORM TO

Add’l. Employee

Contribution



Employee Only

-0-

YOUR PERSONNEL OFFICE



Employee Plus Spouse

$1.86 per pay period



Employee Plus Child

$1.97 per pay period



Employee Plus Children

$1.97 per pay period



Employee Plus Family

$5.08 per pay period

NAMES OF DEPENDENTS TO BE COVERED

DATE OF BIRTH

(Including Spouse)

_____/_____/_____

wish to decline Vision Coverage at this time.

______ I

EMPLOYEE SIGNATURE: _______________________________________ DATE: ________________

Vsp Enrollment Form

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