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.
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.
fill in the following information.
2) Home Address:
4) Date of Birth (mm/dd/yyyy):
5) Home Phone Number:
Work Phone Number:
6) Date of Hire:
9) E-mail address:
10) Coverage Type:
Yourself and another individual
If available and
you are electing family coverage, list below the names of spouse and unmarried
children under 25 years of age.
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.
Social Security Number: _________________________________