VISION INSURANCE Underwritten by National Guardian Life Insurance Company Administered by: Superior Vision Services White Rock Road Rancho Cordova, CA 95670 Enrollment / Change Form Please print and complete all sections. A: Add (enroll) T: Terminate C: Change (change of name or coverage) GROUP/EMPLOYEE INFORMATION Group Name Group Number Location Effective Date Date of Hire School Board of Lake County 29384 A Sex Last Name First Name M.I. Date of Birth Social Security Number M T F C Home Street Address City/State/Zip Home Phone Work ( ) ( ) Email Address Cell ( ) ELECTION(S) Check One Employee Employee + Waived due to Waive Enhanced Plan Only Family other coverage Basic Plan FAMILY INFORMATION (Only those eligible may be enrolled.) A: Add (enroll) T: Terminate C: Change (change of name or coverage) A Sex Last Name (spouse/domestic partner) Name M.I. Date of Birth M T F C Last Name (dependent) First Name M.I. Date of Birth Child unmarried and A Sex full-time student or M T handicapped? F C Yes No A Sex Last Name (dependent) First Name M.I. Date of Birth M T Yes No F C A Sex Last Name (dependent) Name M.I. Date of Birth M T Yes No F C A Sex Last Name (dependent) Name M.I. Date of Birth M T Yes No F C A Sex Last Name (dependent) First Name M.I. Date of Birth M T Yes No F C A Sex Last Name (dependent) First Name M.I. Date of M T Yes No F C Employee Signature: ___________________________________________________ Date: __________________ Do you or any of your dependents have other vision insurance? Yes No If yes, please give: Policyholder and Insurance Company . Declination of coverage must be accompanied by the Employee’s signature above. CALIFORNIA LAW PROHIBITS AN HIV TEST FROM BEING REQUIRED OR USED BY HEALTH INSURANCE COMPANIES AS A CONDITION OF OBTAINING HEALTH INSURANCE COVERAGE. Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.
VISION INSURANCE Underwritten by National Guardian Life Insurance Company Administered by: Superior Vision Services White Rock Road Rancho Cordova, CA 95670 Enrollment / Change Form Please print and complete all sections. GROUP/EMPLOYEE INFORMATION A: Add (enroll) T: Terminate C: Change (change of name or coverage) Group Name School Board of Lake County Group Number 29384 Location Effective Date Date of Hire A T C Sex M F Last Name First Name M.I. Date of Birth Social Security Number Home Street Address City/State/Zip Home Phone ( ) Work ( ) Email Address Cell ( ) Check One Enhanced Plan Basic Plan ELECTION(S) Employee Employee + Waived due to Waive Only Family other coverage FAMILY INFORMATION (Only those eligible may be enrolled.) A: Add (enroll) T: Terminate C: Change (change of name or coverage) A T C Sex M F Last Name (spouse/domestic partner) Name M.I. Date of Birth A T C Sex M F Last Name (dependent) First Name M.I. Date of Birth Child unmarried and full-time student or handicapped? Yes No A T C Sex M F Last Name (dependent) First Name M.I. Date of Birth Yes No A T C Sex M F Last Name (dependent) Name M.I. Date of Birth Yes No A T C Sex M F Last Name (dependent) Name M.I. Date of Birth Yes No A T C Sex M F Last Name (dependent) First Name M.I. Date of Birth Yes No A T C Sex M F Last Name (dependent) First Name M.I. Date of Yes No Employee Signature: ___________________________________________________ Date: __________________ Do you or any of your dependents have other vision insurance? Yes No If yes, please give: Policyholder and Insurance Company . Declination of coverage must be accompanied by the Employee’s signature above. CALIFORNIA LAW PROHIBITS AN HIV TEST FROM BEING REQUIRED OR USED BY HEALTH INSURANCE COMPANIES AS A CONDITION OF OBTAINING HEALTH INSURANCE COVERAGE. Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.
VISION%20Enrollment%20Application%202014.docx