Fillable Avesis Advantage Vision Care Employee Enrollment Form printable pdf download

Avesis Advantage Vision Care Employee Enrollment Form

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MACY C. O’BRIEN SCHOOL DISTRICT #90 & PINAL COUNTY SPECIAL EDUCATION

Cheer One80

12345-1234

30781-1104

900

PLEASE PRINT LEGIBLY

AVESIS ADVANTAGE VISION CARE EMPLOYEE ENROLLMENT FORM

Underwritten by Avesis Insurance Incorporated Phoenix, Arizona

TO BE COMPLETED BY THE EMPLOYEE

Employee Last Name

Employee First Name

Date of Birth

Social Security Number

Sex

Male

Female

Street Address

Apartment No.

City

State

Zip Code

Do you wish to cover your eligible dependents?

Yes

If yes, complete the following:

Dependent Name

Date of Birth

FIRST

LAST

Spouse /

Domestic Partner

Child

I would like to cover additional eligible dependents

(PLEASE LIST ON A SECOND ENROLLMENT FORM)

I authorize deductions from my earnings at the required contributions towards the cost of the coverage.

I certify that I am eligible to participate and that the above information is correct.

Signature

Date

AIIENRF

AII-AVP1

By signing above, I understand that I must remain enrolled during the Benefit Plan period.

TO BE COMPLETED BY THE EMPLOYER

New Enrollment

Add

Change

Cancel Coverage

Dependent(s)

Address

Phone

Policy Holder

Name

COBRA

Dependent(s)

Reason for Change

Employment Status

___________________________________________

Qualifying Event:

(PLEASE STATE)

Requested Effective Date

Date of Employment

09/09

Avesis Advantage Vision Care Employee Enrollment Form

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