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Voluntary Vision Care Enrollment Form

Fields marked with * are required.
Contact Information
*First Name:
 Middle Initial:
*Last Name:
*Address:
 Address 2:
*City:
*State:
*Zip:
*Home Phone:
 Work Phone:
*Email:
*Gender:
*Birth Date:
*NYSUT Member ID:
Vision Plan Coverage Options
*Plan Year
*Coverage Type:
 
Credit Card Information
*Credit Card Type:
*Card Number:
*3 Digit Security Code (from back of card)
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*Expiration: Month       Year 

Note: Members who defraud or attempt to defraud the NYSUT Member Benefits Trust-endorsed Voluntary Vision Plan or who knowingly give false or misleading information are subject to a penalty, which may include suspension of eligibility for all Plan benefits. Members are responsible for notifying the Plan Office of any changes in marital and/or dependent status by submitting a Change of Status Card available from NYSUT Member Benefits Trust.

The Davis Vision Voluntary Vision Plan is a NYSUT Member Benefits Trust (Member Benefits)-endorsed program. Member Benefits has an endorsement arrangement of 7.7% of premium. All such payments to Member Benefits are used solely to defray the costs of administering its various programs and, where appropriate, to enhance them. Member Benefits acts as your advocate; please contact Member Benefits at 800-626-8101 if you experience a problem with any endorsed program.

Agency fee payers to NYSUT are eligible to participate in NYSUT Member Benefits-endorsed programs.