Online Enrollment - Superior Vision
Online Enrollment - Superior Vision
Effective Date
Member Information
First Name
*
Last Name
*
School Location
*
Social Security Number
*
Mailing Address
Mailing Address
Mailing Address
Mailing Address
Mailing Address
Mailing Address
State
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Mailing Address
Phone Number
*
Email
*
Date of Birth
*
Gender
*
M
F
For Employee-Only Coverage:
I wish to cancel my insurance.
Coverage Level
*
Select Your Level of Coverage
Employee Only ($9.12)
Employee and Spouse ($17.95)
Employee and Children ($17.61)
Employee and Family ($26.72)
Cancel Coverage ($0.00)
Dependent Coverage Information
Last Name, First Name
Superior Vision
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Drop
Change
Relationship
Gender
*
M
F
DOB
Riders and Disclaimers
I hereby apply for group insurance for which I am eligible or may become eligible. If contributions are required, I hereby authorize my employer to payroll deduct those contributions from my salary. I am signing up for group insurance until the next enrollment period except in the case of a life event.
Signature Block
Your Signature
*
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Date Signed
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