Vision Application - 3183

Vision Application - 3183

Vision Application

AFSCME Local 3183
AFSCME Member Benefits is offering two supplemental vision plans through Reliance Matrix, an A++ rated carrier. The details of the two plans can be found at AFSCMEMemberBenefits.com/Vision.

The following are the monthly premiums:

VSP/Sharper Vision
- Employee: $9.32
- Employee + Spouse: $18.20
- Employee + Children: $16.28
- Employee + Spouse & Children: $25.16
EyeMed/TrueView
- Employee: $7.84
- Employee + Spouse: $15.60
- Employee + Children: $14.20
- Employee + Spouse & Children: $21.92
Application
Name*

First NameLast Name
Email*
example@example.com
Gender*
Employee Date of Birth*

MonthDayYear
Date
Employer*
Employee Date of Hire*

MonthDayYear
Date
Employee Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Vision Enrollment*
Vision Plan*
Dependent Information

Required for all participating family members
Dependent #1
Dependent #1 Date of Birth

MonthDayYear
Date
Dependent #2
Dependent #2 Date of Birth

MonthDayYear
Date
Dependent #3
Dependent #3 Date of Birth

MonthDayYear
Date
Dependent #4
Dependent #4 Date of Birth

MonthDayYear
Date
Dependent #5
Dependent #5 Date of Birth

MonthDayYear
Date
Additional dependent information
Signature*

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