Enrollment Kit - vision plan of america (vision)
This checklist is provided as a guide. The carrier may require additional items and documentation. Please refer to the carrier's underwriting guidelines for a complete list of requirements. Please use the latest version of forms.
Our goal is to process your new group enrollment easily and efficiently in order to provide you and your client with a quick approval. The following list outlines Vision Plan of America’s case submission requirements.
- Group Application:
- HMO - VPA Group Application and Subscriber Agreement - Please print and include correct Benefit Matrix
- HMO Vision - Benefit Matrix Plan 2 (12, 12, 12)
- HMO Vision - Benefit Matrix Plan 2 (12, 12, 24)
- HMO Vision - Benefit Matrix Plan 3 (12, 24, 24)
- PPO - Avesis Group Application - Effective 1/1/2016
- Member Enrollment Forms:
- HMO Vision - Employee Enrollment Form (VPA)
- PPO Vision - Employee Enrollment Form (Avesis)
- Binder Check (including admin fee):
- HMO Check payable to “Vision Plan of America”
- PPO Check payable to “Avesis”
There is a $10.00 monthly administration fee per group
PPO Group Application Instructions:
- PPO Group Application
- Section I – Group Information (please include Tax ID Number)
- Section II – Plan Information (Avesis Advantage Vision Plus Plan)
- Section III – Premium Information (Voluntary or Employer Sponsored)
- Section IV – Eligibility (please select, usually type 1 (all full-time employees)
- Section V – Effective Date
- Section VI – Employer Signature (mandatory)
- Section VII – Broker Information
- PPO Employee Enrollment Form
Broker Licensing: Agent Service Agreement (if not already appointed).
|After approval, prior carrier termination letter must be submitted by the employer or broker.|
For other useful or older documents, please refer to the Forms database.