Vision Service Plan Enrollment/change Of Status Form
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1Group Name: Nonprofit Resources
Group # 12065657
VISION SERVICE PLAN ENROLLMENT/CHANGE OF STATUS FORM
EMPLOYER NAME (Required)
EFFECTIVE DATE (Required)
Employee’s Last Name
First Name
M.I.
DOB
Social Security #
Spouse’s Last Name
First Name
M.I.
DOB
Social Security #
(Children)
Last Name
First Name
M.I.
DOB
1.
2.
3.
4.
5.
6.
NEW ENROLLMENT
HIRE DATE: ______________________________________
I hearby authorize and direct my employer to deduct from my salary each month the amount of monthly
vision premium, as required, to be paid by me and to remit the same to Nonprofit Resources, Inc.
Plan Type:
Plan C
Plan A
(12-month)
(24-month)
CHANGE OF STATUS
If this form is being completed to change information previously submitted, please check one of the
following:
Addition of Dependents
Deletion of Dependents
Birth
Date ____________
Death
Marriage
Date ____________
Divorce
Other ________________________
Child not eligible because of age
Correction of an error _________________________________________________________
TERMINATION OF COVERAGE
If coverage is being terminated, please check one of the following:
Termination of Employment
Date:___________________
COBRA (If member would like to continue)
Date: __________________
Other_______________________________________________________________________
The information on this form is complete and accurate.
Employee Signature
Date
VSPenrollmentform.doc
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