<Font color = gray>Vision Insurance Applicant Information<P></font color>


Vision Plan of America 
B-1 Online Application

(credit or debit cards only)

*** CALIFORNIA ONLY! ***

Vision Insurance Applicant Information

Name*
Email Address*
Address*
Suite / Unit
City
State
Zip
Phone*
Birthdate
Social Security Number
Employer (if applicable)
 .
 Covered Dependents - List Eligible Dependents (Same Residence)
 .
Spouse
Birthdate
Child 1
Birthdate
Child 2
Birthdate
Child 3
Birthdate
 .
Don't Forget the OPTOMETRIST CODE... ENTER IT HERE > > > > > > > > > > >*
Need the Provider Directory? (Click Here)
 .
 *** PAYMENT INFORMATION - Check the box for either "ANNUAL" or "MONTHLY" premium ***

(Also check Individual, Member + 1, or Family)

 .
I Wish To Pay My ANNUAL PREMIUM PAY ANNUAL PREMIUM IN FULL
Individual ($114.00) $114.00 - Individual
Member + 1 Dependent ($195.00) $195.00 - Member + 1 Dependent
Family ($245.00) $245.00 - Family
 A one-time non-refundable $10.00 enrollment fee is included.
 .
I Wish To Pay My Premium MONTHLY PAY MONTHLY PREMIUM (Credit Card ACH)
Individual $9.50 - Individual
Member + 1 Dependent ($17.60) $17.60 - Member + 1 Dependent
Family ($22.40) $22.40 - Family
 A one-time non-refundable $10.00 enrollment fee will be added to your first month's fees.
 .
 .
 I wish to enroll in the Vision Plan or America Program. I understand that all necessary
 services will be provided as described in the Evidence of Coverage and this contract
is for a minimum of 24 months. I AGREE (This box must be checked)
 .
 CREDIT CARD INFORMATION
Type of Card*
Card Number*
Expiration Date*
Name on Card*
 .
Requested Effective Date (1st of the month)
How did you hear about us?
Who is Your Agent?*
Additional Notes
 .
 * Required Fields
 .
PRINT OUT AN APPLICATION TO FAX IN (Click Here)
 .
 

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.

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