eyecare_enrollment

The Eye and Vision Center Eyecare Advantage Program Enrollment Form

Company Name*

Contact Name*

Address*

Phone*

City*

State*

Zip*

Fax

Email*

Number of Employees*

This company would like to enroll in The Eye and Vision Center Eyecare Advantage Program.
We have chosen the following payment options:

The Company will pay for and/or provide the following benefit for all Employees:

One Comprehensive Eye Exam (employees will pay for dress eyewear and contact lenses at the discounted rate)

every:

12 mo 24 mo

One Comprehensive Eye Exam plus the following Dress Eyewear or Contact Lenses allowance:

every:

12 mo 24 mo

every:

12 mo 24 mo

All emplyees will pay for their own eye exams and dress eyewear and contact lenses at the discounted rate.

Additionally, the Company will pay for the following benefit(s) for the employee's spouse and dependent children:

Comprehensive Eye Exam every:

12 mo 24 mo

Dress Eyewear Allowance every:

12 mo 24 mo

Contact Lenses Allowance every:

12 mo 24 mo

The employee's spouse and dependent children will receive the same discounted rate regardless of the options chosen above.

Note: If the company will pay for any amount of the employee's eyecare, please fill out the separate payment agreement form.