Individual Enrollment Form Select Plan:*A Pair and a Spare VisionBest Choice Dental & VisionVIP Premier VisionEmerald Dental & VisionTo apply for the Pediatric Vision Plan, please complete and fill out the PDF Brochure. Emerald Dental & Vision PremiumsMonthly PaymentsAnnual Payments Individuals$29$348 Couple$49$588 Family$79$948 Enrollment Fee$16Waived Best Choice Dental & Vision PremiumsMonthly PaymentsAnnual Payments Individuals$15$180 Couple$25$300 Family$39$468 Enrollment Fee$16Waived VIP Premier Vision PremiumsMonthly PaymentsAnnual Payments Individuals$12$144 Couple$22$264 Family$33$396 Enrollment Fee$16Waived A Pair and a Spare Vision PremiumsMonthly PaymentsAnnual Payments Individuals$6$72 Couple$9$108 Family$12$144 Enrollment Fee$16Waived Coverage for:* Myself Spouse and Myself My Family Payment Frequency Monthly Annually ($16 one-time non-refundable enrollment fee is waived) Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone* Language Preference Birthdate (mm/dd/yy)* Covered DependentsList Eligible Dependents (Same Residence)Spouse Name Spouse Birthdate (mm/dd/yy) Child #1 Name Child #1 Birthdate (mm/dd/yy) Child #2 Name Child #2 Birthdate (mm/dd/yy) Child #3 Name Child #3 Birthdate (mm/dd/yy) If you have additional dependents, please list their information at the comments box at the bottom of this form.Provider SelectionVision Provider Code* Vision Provider SearchDental Provider Code* Dental Provider DirectoryAgent Code (if applicable) Promo Code (if applicable) Comments or Additional InformationI wish to enroll in the Vision Plan of America Program. THIS CONTRACT IS FOR A MINIMUM OF 12 MONTHS from the effective date and renew at 12 month increments. I understand that all necessary services will be provided as described in the Evidence of Coverage. I hereby authorize Vision Plan of America or its designate to charge my credit card/checking account each month's applicable Dental and/or Vision premium to be credited to my account with Vision Plan of America. This authority is to remain in full force and effect until I notify Vision Plan of America in writing of my termination, thirty days thereafter Dental and/or Vision benefits will end. If the benefits are utilized the contract will remain in effect until the end of the term. This policy may be cancelled within three days of application with written notice to Vision Plan of America.* I agree to the above terms and conditions. A VPA service team member will contact you to complete the application.