Vision Enrollment/change Form
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1MMEHT OFFICE USE ONLY
Subgroup No.
Maine Municipal
Effective Date
Employees Health Trust
Status
60 COMMUNITY DRIVE
Entered by:
AUGUSTA, MAINE 04330-9486
VSP VISION PLAN
Application for Enrollment/Change
PLEASE PRINT
Employer
Enrollment Reason:
1.
New Hire
EMPLOYER
Newly Eligible on (date & reason)____________________
Date of Employment
Hours worked per week
SECTION
New Group (initial enrollment)
Open Enrollment
Portability/Qualifying Event
Employee: Complete this section only if you are enrolling in the Vision Plan coverage.
If you do not wish to enroll, please complete the “Election Not to Enroll” section below.
I elect to be insured at
Employee Only
Employee/Spouse
Employee/Child
Family coverage and
2. P
LAN
hereby authorize my employer to withhold from payroll the amount necessary to make coverage effective.
C
HOICE
Employee Legal Name
Date of Birth
Gender
Social Security Number
3.
Male
Female
N
,
AME
Mailing Address
Phone (home/cell)
ADDRESS
& TELEPHONE
Town
State
Zip
Phone (work)
You may apply to cover your legal spouse, domestic partner (DP) (provided your employer offers this benefit and the Trust receives a completed affidavit
verifying qualification) and children between birth and 26 years of age.
Name change – provide previous name: _______________________________________
4.
Type of change:
Address change
Add dependent(s) listed in section 5 below
Drop dependent(s) listed in section 5 below
C
HANGE
S
TATUS
Reason for change: Date of change or event ____________________
Adoption
Birth
Court order
Covered by other insurance
Death
Discharge from the Military
Divorce
Dissolution of Domestic Partnership
Entrance to the Military
Involuntary loss of coverage
Marriage
Other _____________________
Gender
Date of Birth
5.
Name (Last, First, MI)
Male
Female
Month/Day/Year
F
AMILY
Spouse or
Domestic Partner
I
NFORMATION
(
IF ELECTING
Child
FAMILY
)
COVERAGE
Child
Child
I am requesting coverage for myself and all dependents listed. All statements and answers I have given are true and complete. I
6.
understand it is a crime to knowingly provide false, incomplete or misleading information to obtain insurance or benefits coverage for
the purpose of defrauding the plan or insurance carrier. Penalties may include imprisonment, fines or denial of insurance benefits. I
SIGNATURE
understand all benefits are subject to conditions stated in the Plan Document.
Employee Signature: ______________________________________________
Date: ____________________
7.
I elect not to enroll in VSP Vision coverage at this time. I understand that if I choose to enroll at a later date,
enrollment will only be available during the open enrollment period.
E
LECTION
NAME (print) __________________________________________
EMPLOYER ___________________________________________
N
OT TO
E
NROLL
SIGNATURE __________________________________________
DATE ________________________________________________
For questions, please call the Health Trust at 207-621-2645 or (within Maine) 1-800-852-8300 FAX (207) 624-0166
HT016
08/16
Return Form to MMEHT. Please make a copy to retain for your records.
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