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  Main >  Insurance Enrollment Form MVCCPA Benefits Fund > Insurance Enrollment Form

This page is to enable New Members online enrollment
in the Davis Vision eye care
benefit, brought to you by the
newly established PA Benefit Fund.

Signed, completed form need to be return to Jason Yager, xxXXX,
prior to enrollment to be processed.

If you have questions about enrollment at this point,
please contact the Chair of the PA Benefit Fund, Justin Wilcox.

New members become eligible for benefits after six months.


Please fill in the following information.

1) Last Name: First Name Middle Initial

2) Home Address:

3) City: State: Zip Code:

4) Date of Birth (mm/dd/yyyy):

5) Home Phone Number: Work Phone Number:

6) Date of Hire:

7) Sex: Male Female

9) E-mail address:

10) Coverage Type: Individual Yourself and another individual Family

If available and you are electing family coverage, list below the names of spouse and unmarried children under 25 years of age.

  • Unmarried children ages 19 to 25 are eligible for benefits only if they are fulltime students.
  • Unmarried children 19 years of age or older, who are incapable of self-support because of mental of physical disability are covered provided that the disability began before the age of 19.
First
Name
Last Name
(if different)
Middle
Initial
Relationship
Date of Birth
(mm/dd/yyyy)
Full-Time
Student
1)
Spouse
Daughter
Son
None

Yes
No
2)
Spouse
Daughter
Son
None

Yes
No
3)
Spouse
Daughter
Son
None

Yes
No
4)
Spouse
Daughter
Son
None

Yes
No
5)
Spouse
Daughter
Son
None

Yes
No
6)
Spouse
Daughter
Son
None

Yes
No
7)
Spouse
Daughter
Son
None

Yes
No
8)

Spouse
Daughter
Son
None

Yes
No
9)
Spouse
Daughter
Son
Yes
No
10)
Spouse
Daughter
Son
Yes
No
11)
Spouse
Daughter
Son
Yes
No
12)
Spouse
Daughter
Son
Yes
No
13)
Spouse
Daughter
Son
Yes
No
14)
Spouse
Daughter
Son
Yes
No
15)
Spouse
Daughter
Son
Yes
No

Note: Members who defraud or attempt to defraud the NYSUT Group Benefits Plan or who knowingly give false or misleading information are subject to a penalty which may include suspension of eligibility of all Plan benefits. Members are responsible for notifying the Plan Office of any changes in marital and/or dependent status by submitting a Change of Status Card which is available from the Plan office.

I verify that the above information is true and accurate.
Signature: ________________________

Social Security Number: _________________________________


 

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