Vision Plan Enrollment Form - United Healthcare Vision

TO BE COMPLETED BY GROUP BENEFITS OFFICE:

Effective Date: _________/____________/_____________

Group # _________________________________________

Plan Variation Vision _______________________________

Vision Plan Enrollment Form

Reporting Code Vision _____________________________

Organization Name:

_________________________________________________________________________________________________________________________________________________

1. Check the Appropriate Boxes

REASON FOR CHANGE IN STATUS

Coverage Desired

New Enrollment

Change of Status/Address

$ ________

Termination

Death

Marriage

Divorce

Employee Only

Newborn Child

Last Name

Other Insurance

Move to COBRA

Open Enrollment

$ ________

Employee + Family

Adoption/legal custody

Legal custody of parent

COBRA

Dependent child married/

_______

reached age limit

EFFECTIVE DATE:

2. Employee Information (please print clearly):

Social Security Number ______-______-______

Birth Date ________/________/__________

Home Phone (______)______-______ Work Phone (______)______-______

Your Name: _____________________________________________________________________________________________________________________________________________________________

(First)

(Middle Initial)

(Last)

Address: _______________________________________________________________________________________________________________________________________________________________

(City)

(State)

(Zip)

3. List All Eligible Family Members Below (if electing dependent coverage):

First Name

Last Name

Birth Date

Full-Time Student?

Gender

not applicable

_______/_______/_________

M /

F

Spouse ________________________________________________________________________________________________

_______/_______/_________

Yes

No

M /

F

Child

________________________________________________________________________________________________

_______/_______/_________

Yes

No

M /

F

Child

________________________________________________________________________________________________

Yes

No

_______/_______/_________

M /

F

Child

________________________________________________________________________________________________

_______/_______/_________

Yes

No

M /

F

Child

________________________________________________________________________________________________

_______/_______/_________

Yes

No

M /

F

I agree to continue enrollment in the vision plan for a period of 12 months. I authorize on behalf of myself and anyone added to this application (“US”) the use of a Social Security Number for

purpose of identification. The information provided on this application is accurate and complete to the best of my knowledge and belief. I understand and agree that any omissions or incorrect

statements knowingly made by US on this application may invalidate my and/or my dependents’ coverage.

Florida Residents Only: NOTICE: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER FILES A STATEMENT OF CLAIM OR AN

APPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS GUILTY OF A FELONY OF THE THIRD DEGREE.

Your Signature _____________________________________ Date_____________________

UnitedHealthcare Vision is underwritten by United HealthCare Insurance Company (except NY) and United HealthCare Insurance Company of New York (NY only)

2008 – EF2t