|
Vision Insurance Applicant Information
Vision Plan of America B-1 Online Application (credit or debit cards only)
*** CALIFORNIA ONLY! ***
By clicking Submit, I hereby authorize VISION PLAN OF AMERICA to charge my credit card/checking account each months applicable Vision Plan premium to be credited to my account with Vision Plan of America or to charge the annual premium in full - whichever box is checked above in the online application. 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 vision benefits will end. By clicking Submit, I am authorizing an online signature and will provide a hard copy signature upon request of VPA.
|