Vision Insurance

For 2014, I wish to: <insert drop down menu>

Drop down menu options:

Keep the same

Waive enrollment

Change plans

If "Change plans" is selected, add this drop down menu:

I wish to change my plan to: <insert drop down menu>

Drop down menu options:

Single

Employee + Spouse

Employee + Child(ren)

Family

If "Employee+Spouse" is selected, prompt for the following:

Spouse/Partner Information:

Name: _____________________

Social Security Number: _______________________

Date of Birth: ______________________

Gender: Check box for male or female

Address (if not living with employee): _____________________________________________

If "Employee + Child(ren)" is selected, prompt for the following:

Child(ren) Information:

Name: _____________________

Social Security Number: _______________________

Date of Birth: ______________________

Gender: Check box for male or female

Address (if not living with employee): _____________________________________________

(Insert option to add more and repeat as many times as necessary for the "Child(ren) Information")

If "Family" is selected, prompt for the following:

Spouse/Partner Information:

Name: _____________________

Social Security Number: _______________________

Date of Birth: ______________________

Gender: Check box for male or female

Address (if not living with employee): _____________________________________________

Child(ren) Information:

Name: _____________________

Social Security Number: _______________________

Date of Birth: ______________________

Gender: Check box for male or female

Address (if not living with employee): _____________________________________________

(Insert option to add more and repeat as many times as necessary for the "Child(ren) Information")

If "Waive enrollment" is selected OR if current election is "Waived" AND "Keep the same" is selected for 2014, insert the following:

<INSERT CHECK BOX> I am declining or terminating coverage because my dependents or I have other coverage.

<INSERT CHECK BOX> I (we) do not have other coverage, but am (are) declining or terminating coverage at this t