Office of Pensions - Vision Application or Refusal
You need to complete this form to sign up for, change, or terminate your participation in this program.
Effective Date:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
PERSONAL INFORMATION:
Please complete all of the Personal Information
Pension ID or SSN:
*
Date of Birth:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name:
*
First Name & Middle Initial
Last Name
Phone:
Format: (000) 000-0000.
Work Phone:
Format: (000) 000-0000.
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Reason for Vision Application:
Please Check the Applicable Box or Boxes:
*
New Enrollment
Termination/Refusal
Change of Dependents
Coverage Change
Address Change
Name Change
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Coverage Options
Please Select your Covers Option:
*
Individual
Individual & Child(ren)
Individual & Spouse
Family
Number of Dependents:
*
Please Select
0
1
2
3
4
5
6
7
8
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Vision Plan
Please Select One Vision Plan:
*
High
Low
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Personal & Spousal Information:
Personal Information
This has been pre-populated from the earlier information where possible.
Name:
*
First Name & Middle Initial
Last Name
Birth Date:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
SSN:
*
Spousal Information
Name
*
First Name & Middle Initial
Last Name
Birth Date:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
SSN:
*
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Dependent Information
This will be where you enter the information for the dependents that you are submitting with this application.
Dependent #1
Status Information:
Fulltime Student
Disabled
Gender:
*
Male
Female
Name:
*
First Name
Last Name
Birth Date:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
SSN:
*
Dependent #2
Status Information:
Fulltime Student
Disabled
Gender:
*
Male
Female
Name
*
First Name & Middle Initial
Last Name
Birth Date:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
SSN:
*
Dependent #3
Status Information:
Fulltime Student
Disabled
Gender:
*
Male
Female
Name:
*
First Name & Middle Initial
Last Name
Birth Date:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
SSN:
*
Dependent #4
Status Information:
Fulltime Student
Disabled
Gender:
*
Male
Female
Name:
*
First Name & Middle Initial
Last Name
SSN:
*
Birth Date:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Dependent #5
Status Information:
Fulltime Student
Disabled
Gender:
*
Male
Female
Name:
*
First Name & Middle Initial
Last Name
Birth Date:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
SSN:
*
Dependent #6
Status Information:
Fulltime Student
Disabled
Gender:
*
Male
Female
Name:
*
First Name & Middle Initial
Last Name
Birth Date:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
SSN:
*
Dependent #7
Status Information:
Fulltime Student
Disabled
Gender:
*
Male
Female
Name:
*
First Name & Middle Initial
Last Name
Birth Date:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
SSN:
*
Dependent #8
Status Information:
Fulltime Student
Disabled
Gender:
*
Male
Female
Name:
*
First Name & Middle Initial
Last Name
Birth Date:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
SSN:
*
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By my signature below, I hereby certify the benefit election and statements made on this form are true and my choice. I have completed the required forms necessary to enroll in the vision election noted. I understand that by completing and signing the required forms, I am affirming that any dependents noted are eligible dependents as defined by the State's Eligibility and Enrollment Rules (found on the SBO website Section 2.0). I understand this is a binding election. Once enrolled, I may not drop or change coverage during the plan year unless I experience a qualifying event that warrants the change. During the next open enrollment period, I can drop or change my vision election.
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature
*
Submit
Should be Empty: