Enrollment/change/waiver Form - Deltavision
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1ENROLLMENT/CHANGE/WAIVER FORM - DeltaVision
NOTE: COMPLETING THIS FORM DOES NOT GUARANTEE COVERAGE.
EMPLOYER USE ONLY
GROUP NUMBER
______________
______________
______________
______________
EFFECTIVE DATE ___________________
ENROLLEES MUST COMPLETE THIS SECTION
EMPLOYEE’S LAST NAME
FIRST
M.I.
SOCIAL SECURITY NO.
DATE
MO
DAY
YR
SEX
OF
BIRTH
F
M
HOME ADDRESS - STREET
CITY
STATE
ZIP
EMPLOYER NAME AND LOCATION (CITY & STATE)
DATE
MO
DAY
YR
OF
HIRE
LIST ALL ELIGIBLE FAMILY MEMBERS TO BE COVERED
RELATIONSHIP
DATE OF BIRTH
NO.
LAST NAME (IF DIFFERENT)
FIRST
M.I.
SON
DAU.
MO
DAY
YR
EMPLOYEE
1
SPOUSE
2
3
4
5
6
REASON FOR SUBMITTING THIS FORM
WHAT TYPE OF COVERAGE ARE YOU APPLYING FOR?
NEW ENROLLEE
REHIRE (Date: ___________________)
DATE
EMPLOYEE ONLY
EMP. + ONE
EMP. & TWO OR MORE
NONE (WAIVE)
OCCURRED
IF THIS IS FOR CHANGE, WHAT IS THE REASON?
YOUR MARITAL STATUS
BIRTH/ADOPTION (Name:______________________________)
_______________
SINGLE
MARRIED
MARRIAGE/
DIVORCE
_______________
ADD/
DROP DEPENDENT (Name: _____________________)
_______________
AT THE TIME THIS PLAN BECOMES EFFECTIVE, WILL YOU BE COVERED BY ANY
TERMINATION OF BENEFITS (Reason: _____________________)
_______________
OTHER VISION PLAN?
NAME CHANGE (Former Name: ___________________________)
_______________
YES
NO
ADDRESS CHANGE _______________
AT THE TIME THIS PLAN BECOMES EFFECTIVE, WILL YOUR SPOUSE BE COVERED
GROUP TRANSFER (From ______________ to _______________)
_______________
BY ANOTHER VISION PLAN?
COBRA APPLICATION
_______________
YES
NO
Accept Coverage
Waive Coverage
X
SEE BELOW FOR PROVISIONS ON ACCEPTANCE OR WAIVER
SIGNATURE IS REQUIRED
DATE
OF THESE BENEFITS.
Acceptance of Coverage
Waiver of Coverage
I accept the insurance provided by my employer’s group
I understand that if I decide not to apply for coverage, or if
insurance plan. I authorize deductions from my earnings
I apply only for single coverage even though I am eligible
for the required contributions toward the cost of insurance.
for family coverage, any subsequent application will be
(This authorization applies only if employee contributions
subject to the applicable terms and conditions of the Master
are required.) I understand that by accepting insurance, I am
Agreement to Provide Vision Benefi ts, which may require ad-
required to remain enrolled as a covered employee and can-
ditional limitations and waiting periods. I also understand
not make an elective change in the coverage selected until
that Wyssta Insurance reserves the right to reject such an
the next open enrollment period, if there is one provided for
application.
in the Master Agreement to Provide Vision Benefi ts.
DeltaVision is administered by Wyssta Insurance, a Delta Dental of Wisconsin Company, in partnership with EyeMed Vision Care.
2/06
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