ࡱ> sur` |?bjbjss q $86D: '* T^^^^HD'!&&&&&&&$(h+&]![@!!&^^D'&&&!:8^^&&!&&&&^ ܂ "F&&Z'0'&+K"+&+&!!&!!!!!&&%!!!'!!!!: : : : : :  Baltimore, MD Vision Plan Enrollment Form Organization Name:  FORMTEXT       I. Check the Appropriate BoxesCoverage Desired  FORMCHECKBOX  Employee Only  FORMCHECKBOX  Employee + Spouse  FORMCHECKBOX  Employee + Child(ren)  FORMCHECKBOX  Employee + Family   FORMCHECKBOX  New Enrollment  FORMCHECKBOX  Change of Status/Address  FORMCHECKBOX  Open Enrollment  FORMCHECKBOX  COBRAREASON FOR CHANGE IN STATUS  FORMCHECKBOX  Termination  FORMCHECKBOX  Death  FORMCHECKBOX  Marriage  FORMCHECKBOX  Divorce  FORMCHECKBOX  Newborn Child  FORMCHECKBOX  Last Name/Address Change  FORMCHECKBOX  Other Insurance  FORMCHECKBOX  Move to COBRA  FORMCHECKBOX  Adoption/legal custody of child  FORMCHECKBOX  Legal custody of parent  FORMCHECKBOX  Dependent child married/reached age limit II. Employee Information (please print clearly): Unique Member ID Number  FORMTEXT       -  FORMTEXT       -  FORMTEXT       Your Name  FORMTEXT       (First) (Middle Initial) (Last) Birth Date  FORMTEXT      /  FORMTEXT      /  FORMTEXT       Address  FORMTEXT        FORMTEXT       Home Phone ( FORMTEXT      )  FORMTEXT       -  FORMTEXT       Work Phone ( FORMTEXT      )  FORMTEXT       -  FORMTEXT       III. List All Eligible Family Members Below (if electing dependent coverage): First Name Last Name Birth Date Full Time Student? Sex Spouse  FORMTEXT        FORMTEXT      / FORMTEXT      / FORMTEXT       not applicable  FORMCHECKBOX M /  FORMCHECKBOX F Child  FORMTEXT        FORMTEXT      / FORMTEXT      / FORMTEXT        FORMCHECKBOX  Yes  F XZ~   źkaQKA3jhCJOJQJUhCJOJQJ hCJh5B*CJOJQJphhCJOJQJ/jh5>*CJOJQJU\mHnHu*jh5>*CJOJQJU\h5>*CJOJQJ\$jh5>*CJOJQJU\h>*CJOJQJhCJOJQJh h5CJ hCJjhCJUmHnHujhCJUmHnHu XZ  Z \ ~xnnn N $If$Iflkdv$$Ifl4+,   04 laf4p $If !$a$ "<<>z? 4 6 8 X \ ^ z | ~   ( ) 7 8 9 J K Y Z [ w x wf!jhCJOJQJU!j_hCJOJQJU!jhCJOJQJU!jwhCJOJQJU!jhCJOJQJU!jhCJOJQJUh>*CJOJQJjhCJOJQJU!jhCJOJQJUhCJOJQJ& # $ % & ' ( I J v w  ;  $If $If$If $If$If N $If      ! / 0 1 ; < J K L [ \ j k l ֿ֮֝֌{j!jhCJOJQJU!jhCJOJQJU!jhCJOJQJU!jhCJOJQJU!j/hCJOJQJU!jhCJOJQJU hCJhCJOJQJjhCJOJQJU!jGhCJOJQJU%    V X t v x F J | ~ ִ֣֒ւ|laNl$j h>*CJOJQJUh>*CJOJQJjh>*CJOJQJU hCJh5B*CJOJQJph!jS hCJOJQJU!jhCJOJQJU!jghCJOJQJU!jhCJOJQJUhCJOJQJjhCJOJQJU!j{hCJOJQJU T F a[$Ifkd $$Ifl~ F 4+"~ d0    4 la  $If]  $IfF H J @TVxkx 2 $If &$If ,$If$Ifkkdu $$Ifl+,   04 lap ,.0:<@ŲşŌyf$jX h>*CJOJQJU$j h>*CJOJQJU$jp h>*CJOJQJU$j h>*CJOJQJU$j h>*CJOJQJUh>*CJOJQJhCJOJQJjh>*CJOJQJU)jh>*CJOJQJUmHnHu(*,@BDNPRXZnpr|~۠ۍzg$jh>*CJOJQJU$j,h>*CJOJQJU$jh>*CJOJQJU$j@h>*CJOJQJU)jh>*CJOJQJUmHnHu$j h>*CJOJQJUh>*CJOJQJjh>*CJOJQJUhCJOJQJ(V[kd$$Ifl- +,04 la  $If$If &$If  fh|~  ѼѼѲѼѲyѼscsXh5CJOJQJh5B*CJOJQJph hCJ$jvh>*CJOJQJU$jh>*CJOJQJU$jh>*CJOJQJUhCJOJQJ)jh>*CJOJQJUmHnHujh>*CJOJQJU$jh>*CJOJQJUh>*CJOJQJ"t6v677~n\\\\\\ * < '$If Tj4 %$If TjB '$If$Ifkkdl$$Ifl+,   04 lap  "$.0246JLNXZ\^rtvѼѼѼyѼѲkZkk!jhCJOJQJUjhCJOJQJU$jmh>*CJOJQJU$jh>*CJOJQJU$jh>*CJOJQJUhCJOJQJ)jh>*CJOJQJUmHnHujh>*CJOJQJU$j h>*CJOJQJUh>*CJOJQJ#(*>@BLNPRThjlvxz|ƻƓƻƻƓƻƻmƓƻƻZƓ$j1h>*CJOJQJU$jh>*CJOJQJU$jEh>*CJOJQJU)jh>*CJOJQJUmHnHu$jh>*CJOJQJUh>*CJOJQJjh>*CJOJQJUhCJOJQJjhCJOJQJU!jYhCJOJQJU"6666$6&6B6D6F6N6P6l6n6p666666666666ֲ֑֡s^֑)jh>*CJOJQJUmHnHu$jh>*CJOJQJUh>*CJOJQJjh>*CJOJQJU!j hCJOJQJU!jhCJOJQJU!jhCJOJQJUUhCJOJQJjhCJOJQJU!jhCJOJQJUORMCHECKBOX  No  FORMCHECKBOX M /  FORMCHECKBOX F Child  FORMTEXT        FORMTEXT      / FORMTEXT      / FORMTEXT        FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX M /  FORMCHECKBOX F Child  FORMTEXT        FORMTEXT      / FORMTEXT      / FORMTEXT        FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX M /  FORMCHECKBOX F Child  FORMTEXT        FORMTEXT      / FORMTEXT      / FORMTEXT        FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX M /  FORMCHECKBOX F I agree to continue enrollment in the vision plan for a period of 12 months. Your Signature Date  FORMCHECKBOX  I decline to joining the vision plan at this time. 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