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standard-title Individual Enrollment Form

Individual Enrollment Form

You are here: Home \ Individual Enrollment Form

Individual Enrollment Form

  • To 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
  • 20/20 Plan Vision PremiumsMonthly PaymentsAnnual Payments
    Individuals$12.75$153
    Couple$25$300
    Family$37$444
    Enrollment Fee$16Waived
  • Covered Dependents

    List Eligible Dependents (Same Residence)
  • If you have additional dependents, please list their information at the comments box at the bottom of this form.
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  • I 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.

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