NEW MEMBER ENROLLMENT

printer image gif

** PLEASE PRINT THIS PAGE ** TO COMPLETE YOUR ENROLLMENT, AND TO BEGIN COVERAGE,
PRINT THIS PAGE, THEN SIGN AND DATE IT, AND MAIL IT TO:

Dennis Krol Insurance
P.O. Box 1818
Frankfort, Kentucky 40602-1818

Call 1-502-875-3477
Fax 1-502-875-3615
krolinsurance@bellsouth.net

After printing and mailing this form, please click the button below to also email a copy of your enrollment form for our records.

Thank you for choosing the Avesis Advantage Vision Plan.

Underwritten by Fidelity Security Life Insurance Company
Enrollment Form Plan #987
Policy #VC16

Employer Name: Commonwealth Of Kentucky
Group #: 10835-1017
Employee First Name:
Middle Name:
Last Name:
Street Address:
Street Address 2:
City:
State:
Zip:
Phone:
Birth Date:
SSN:
Sex:
Agency Department Name:
Company Number:
1st Payroll Deduction Date:
Effective Date:
Deduction Monthly Amount:
Date of Authorization:
Dependents:
Spouse:Birth Date:
CNoChild NameBirth Date 
1 Delete
    

I authorize my employer to deduct my contribution for insurance premium from my wages or salary. Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.

Employee Signature : ___________________________________________ Date : ________________

A-00713KY M-9004
01/04