Enrollment Form

Policy No. VC-95

Retired state employees, you are eligible to purchase the vision insurance but at this time it cannot be payroll deducted via RSA. To purchase please call 334-365-5055.

9182-T3 Prices

EMP - $6.99

E1D - $12.51

FAM - $19.42

9183-T3 Prices

EMP - $8.46

E1D - $14.97

FAM - $22.65

Alabama State Employees Association - *Required Fields

Basic = 9182-T3
Basic Plus = 9183-T3

First Name *

M.I.

Last Name *

Gender *

SSN *

Plan Selection *

Birth Date *

Home Phone *

Work Phone

Email *

Desired Effective Date

Street Address *

Address 2

City *

State *

Zip Code

Coverage Option *

Will this plan replace any existing coverage? YesNo

If yes, name of current vision carrier:

DEPENDENTS (IF APPLICABLE)

First Name	M.I.	Last Name	Gender	Relationship	BirthDate
				Spouse
				Child
				Child
				Child
				Child
				Child

AUTHORIZATION

I AUTHORIZE my employer to deduct my contribution for insurance premium from my wages or salary.

Date Employed: *

Dept/Agency: *

Division: *

Any person who knowingly presents a false or fraudulent claim for payment of loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution, fines or confinement in prison, or any combination thereof.

A-00713AL

Form No. M-9069

Enrollment Form

Retired state employees, you are eligible to purchase the vision insurance but at this time it cannot be payroll deducted via RSA. To purchase please call 334-365-5055.

Alabama State Employees Association - *Required Fields

Basic = 9182-T3 Basic Plus = 9183-T3

AUTHORIZATION

Basic = 9182-T3
Basic Plus = 9183-T3