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Enrolling for Superior Vision
1) Plan Info
Plan Type
*
Add (Enroll)
Terminate
Change (change coverage or name)
Group Name
*
Group Number
*
Effective Date
*
Location
2) Member Information
First Name
*
Middle Initial
Last Name
*
Gender
M
F
Social Security Number
*
Date of Birth
Email
Address
*
U.S. Citizen
*
Yes
No
Home Phone
Work Phone
Cell Phone
3) Add a Dependent (Multiples Allowed)
Action
Select Option
Add
Terminate
Change
Last Name, First Name, MI
*
Gender
Select Option
Male
Female
Social Security #
*
Email
Date of Birth (mm/dd/yyyy)
*
Place of Birth (City and State)
Relationship
Husband
Wife
Civil Union Partner
Domestic Partner
Son/Stepson
Daughter/Stepdaughter
Other
Other
Child Handicap Status
Yes
No
Age when Handicap began:
Add
Remove
4) Completed By Employer
Date of Hire
Status
Full-time
Part-time
Retiree
Occupation
Class
Salary
5) Benefit Elections (Employer determines benefits available for election)
Type
Select One
Dental (high)
Dental (low)
Vision
Plan
*
Select Plan
Member Only
Member/Spouse
Member/Child(ren)
Member/Family
Waive
Monthly Premium
Riders and Disclaimers
Disclaimer Text that is exclusive to each product type.
Signature Block
In the past 12 months, have you had continuous group coverage providing like or similar benefits (for yourself and/or your dependents) with a prior carrier?
Yes
No
If yes, please provide: Policyholder and Insurance Company
Your Signature
Clear
Spouse Signature
Clear
Date Signed
Submit
If you are human, leave this field blank.
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