GENESEE AREA HEALTHCARE PLAN
Davis Vision Enrollment Application Employee Information (Please Print)

Employer Name/Group Number	Reason For Application:
 Addition	 Reinstate	Termination
 Change	 COBRA	WaiveCoverage
	
Employee (Member) First Name / Middle Initial / Last Name
	
Mailing Address
	City
	State
	Zip code
	
Employee (Member) Identification Number if know
	Effective Date
	Employee Status
 Active	 Hourly	Salary
 Retired (Date)
	
	Month
	Day
	Year
		
Employee Phone Number
	Employee Hire Date
Month	Day	Year

Please indicate the change(s) that you need to make to your record:

Check Type of Coverage:

Employee Only	

Employee and Spouse	 Family	 Employee & Child                                          

Employee & Children	

Tobe completedby Account Administratoronly:

10P100000769 Group Number

N/A Payroll Code

001
Subgroup Code	Plan Code

Change of Name Change of Address
Change of Phone

Change Birthdate

Change Effective Date

Change Report Code Existing ________
New ____________

Change in Group No.

Existing      ________ New ____________

Change Enrollment Status to:

Employee Only

Employee/Children

Employee and Spouse

Employee and Child

Family

Complete If Applicable
	First Name / Middle Initial / Last Name
	Social Security Number
	Change
	Effective Date of Change
	Sex
	Check If
	Birth Date*
	
					F/M
	Student
Over 19
	Disabled
	
MM
	
DD
	
YY
	
				MM
	DD
	YY

Self
			 Add  Term
										
Spouse
			 Add  Term
										
 Child  Other
			 Add  Term
										
 Child  Other
			 Add  Term
										
 Child  Other
			 Add  Term
										
 Child  Other
			 Add  Term
										
 Child  Other
			 Add  Term

“I certify that this enrollment information is true and correct.”

Member/Employee Signature	Date * Required for all Employee/dependents

Please send the completed form via fax or email to your corresponding district clerk.	EF00069 7/25/18