Group Vision Master Application

Opticare Vision Services
1901 West Parkway Blvd., Salt Lake, City, UT 84119
800-363-0950 (www.opticarevisionservices.com)
APPLICATION FOR INDIVIDUAL VISION CARE INSURANCE POLICY

Group Vision Master Application

Employer Information
Legal Name of Group/Company
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Type of Business
Email
Name of Human Resources Contact
First Last
Phone of HR Contact
Email of HR Contact
Group Vision Plan
Plan ID
Effective Date
MM slash DD slash YYYY
Monthly Single Premium
Monthly 2 Party Premium
Monthly Family Premium
Plan ID
Copy of Effective Date
MM slash DD slash YYYY
Monthly Single Premium
Monthly 2 Party Premium
Monthly Family Premium
Employer Contribution
Percent or Dollar Amount of Monthly Contribution (please use $ or % symbol)
Enrollment Eligibility
Eligible Employees
- Active Full Time Employees
- Active Part Time Employees
- Dependents
- New Choice
- Other
other
Describe any other eligibility requirements in detail.
Annual Open Enrollment Period
MM slash DD slash YYYY
Total Number of Employees (including part time)
Total Number of Eligible Employees
Comments / Remarks
Representations / Execution of Agreement
I agree that Opticare of Utah may use the name of my business, address and the fact of my participation in this agreement for purposes of publicizing Opticare of Utah’s PPO Network, preparing bids for contracts and other similar marketing purposes.
- Yes
- No
I agree that: (1) the statements and answers given in this application are true, complete, and correctly recorded to the best of my knowledge and belief; (2) this application will be part of the group policy for which I apply; (3) the group policy is a one year contract that is guaranteed renewable in accordance with the terms of the group policy; (4) I will notify the Insurer if any statements or answers given in this application change prior to policy delivery; and (5) I have received the Outline of Coverage. I understand and agree that the policy is to remain in force for a one year period beginning on the effective date of the policy; I understand that this policy is guaranteed renewable each year on the anniversary date of the policy. I understand and agree that I may only elect one open enrollment period per year for the group policy. I understand and agree that the annual enrollment period I indicated under section 4 of this Application will be applied every year, unless I give a written request to Opticare of Utah to change the annual open enrollment period date at least 60 days in advance of the next Policy Anniversary Date. I understand and agree that the requested change in the annual open enrollment date upon approval by Opticare of Utah will be applied to the next policy year that begins on that Policy Anniversary Date. I understand and agree that the first month's estimated premium and fully completed enrollment information for all eligible persons requesting insurance coverage must be submitted with this application before action can be taken on this application. Coverage is not in effect unless and until I receive notification of acceptance from Opticare of Utah. If this application is declined, Opticare of Utah will return the premium deposit submitted with this application. If my coverage is approved, premium is payable in advance of the due date. I understand that Opticare of Utah will rely on the information I provide in determining eligibility for coverage, setting premium rates, and other purposes, and that any misrepresentation or fraudulent statement may result in rescission of the group policy, termination of coverage, increase in premiums, or other consequences as permitted by law. I agree that Opticare of Utah shall be entitled to rely on the most current information in its possession regarding eligibility of employees and their dependents in providing coverage under the policy. I understand and agree that I am responsible for notifying Opticare of Utah promptly of any changes in this information that may affect the eligibility of employees or their dependents, including the addition of newly eligible employees or dependents. I understand that the Certificate of Coverage or Summary Plan Description, and other documents, notices and communications regarding the coverage indicated on this application may be transmitted electronically or by mail to me from Opticare of Utah. No licensed insurance agent is authorized to: (a) make or modify contracts; (b) waive any Insurer rights or requirements; and (c) waive any information the Insurer requests. Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance may be guilty of a crime and may be subject to fines and confinement in prison. Opticare of Utah dba Opticare Vision Services is underwritten by Opticare of Utah, Inc. a Utah Insurance Policy. The policy provides vision benefits only. Review your policy carefully.*
- I agree to the terms of service.
Authorized Signature of Group/Company
State In which policy will be delivered
Agent Name
First Last
Agent License Number
Signature of Licensed Agent

80667

Group Vision Master Application

Employer Information

Group Vision Plan

Employer Contribution

Enrollment Eligibility

Representations / Execution of Agreement

OPTICARE VISION SERVICES

OPTICARE VISION SERVICES

Out of Network Reimbursement Request

Itemized Price(s) Paid