Opticare Vision Services
1901 West Parkway Blvd., Salt Lake, City, UT 84119
800-363-0950 (www.opticarevisionservices.com)

Individual Application

  • Owner (Applicant) - Owner is the Primary Insured

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  • NameSS#Date of Birth 
  • Benefit Selection

  • Premium Payment

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  • I agree that: (1) the statement and answers given in this application are true, and correctly recorded to the best of my knowledge and belief; (2) this application will be part of the contract for which I apply; (3) the policy is a one year contract that is guaranteed renewable in accordance with the terms of the policy; (4) I understand that this policy must remain in force for a 12-month period and that premiums are due for the entire 12 month period; (5) I understand that this policy will be renewed on each policy anniversary date for a new 12-month period unless given written notification to Opticare of Utah to terminate the policy 60 days prior to the policy renewal date. I will notify the insurer if any statements or answers given in this application change prior to policy deliver; and (6) I have received the outline of coverage.

    I herby authorize Opticare of Utah to withdraw premium payments from the financial institution and account named above under section 4 of this application. I understand that this authorization will remain in effect until the financial institution has received and has had reasonable time to act on a written request from me to terminate this agreement. I understand that I can stop a withdraw by notifying the financial institution at least three business days before the withdraw is made. In the event of a withdraw error, I must promptly notify the financial institution to preserve any rights I may have. I understand that I may direct my billing inquiries to Opticare of Utah, 1901 West Parkway Blvd, Salt Lake City Utah 84119.

    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 of 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. The policy provides vision benefits only. Review your policy carefully.

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