Dental & Vision Insurance Enrollment Form

Dental Plan Options
Please see the benefits summaries below to learn more about the coverage differences between each Humana Dental Plan. Additionally, the 2023 cost breakdown is also listed below. WPCC pays $23.44 towards each employee's dental plan premium.
- Humana Dental Plan Basic (Preventative) Benefits Summary
- Humana Dental Plan Preferred (Plan 2) Benefits Summary
Dental Plan Choice*

Humana Dental Plan Basic (Preventative)Humana Dental Plan Preferred (Plan 2)No Dental Insurance (*please keep in mind you will not be eligible to enroll in dental insurance again until open enrollment opens December each year)
Dental Plan Individuals Covered*

EmployeeEmployee & SpouseEmployee & Child(ren)Family
Vision Plan Options
To learn more about the Humana Vision Plan coverage, please see the benefits summary below. Additionally, the 2023 cost breakdown is also listed below.
- Humana Vision Plan Benefits Summary
Vision Plan Choice*

Humana Vision PlanNo Vision Insurance (*please keep in mind you will not be eligible to enroll in vision insurance again until open enrollment in December each year)
Vision Plan Individuals Covered*

EmployeeEmployee & SpouseEmployee & Child(ren)Family
Signature*

Clear
Name*

First NameLast Name
Date*

MonthDayYear
Date
Should be Empty:

Dental Plan Options