USVI Public Records

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Enrollment/Change Form Please print and complete all sections. See instructions below. Underwritten by Combined Insurance Company of America Group Number Client Name Location Code N/A Division Code N/A Client Co Code N/A Effective Date SUBSCRIBER INFORMATION A: Add (enroll) Sex  M  F UVI – Employee ID Last Name (Subscriber) First Name M.I. Date of Birth Mailing Address City/State/Zip Home Phone ( ) FAMILY INFORMATION (Only those eligible may be enrolled.) Add Sex  M  F Last Name (spouse) First Name M.I. Date of Birth Add Sex  M  F Last Name (dependent) First Name M.I. Date of Birth Add Sex  M  F Last Name (dependent) First Name M.I. Date of Birth Add Sex  M  F Last Name (dependent) First Name M.I. Date of Birth Add Sex  M  F Last Name (dependent) First Name M.I. Date of Birth Subscriber Signature: Date: Instructions: Plan name: Legal name of the plan. Group Number: Provided by EyeMed or EyeMed representative. Location code: N/A. Family Information: List only eligible family members who are enrolling. Dependent eligibility is the same as subscriber’s health plan. (A) Add: Open (group) enrollment or new (individual) enrollment during the contract period. (T) Terminate: To terminate enrollment. (C) Change: A change of name, address or phone. Your Authorization: I authorize payment for annual premium by payroll deduction: $4.14 Per Subscriber only $11.00 Per Subscriber + family Once you elect EyeMed vision coverage, you cannot cancel for a 12-month period based upon your enrollment date. Revised for University of the Virgin Islands Participants on 05/2016. SIGN