GET COVERED NOW GRIEVANCE FORM INDIVIDUALS GROUPS BROKERS PROVIDERS SEARCH CONTACT US INDIVIDUAL ENROLLMENT FORM You are here: Home \ Individual Enrollment Form Individual Enrollment Form Select Plan:* A Pair and a Spare Vision To apply for the Pediatric Vision Plan, please complete and fill out the PDF Brochure. A Pair and a Spare Vision Premiums Monthly Payments Annual Payments Individuals $6 $72 Couple $9 $108 Family $12 $144 Enrollment Fee $16 Waived Coverage for:* Myself Spouse and Myself My Family Payment Frequency Monthly Annually ($16 one-time non-refundable enrollment fee is waived) Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone* Language Preference Birthdate (mm/dd/yy)* Provider Selection Vision Provider Code* Vision Provider Search Agent Code (if applicable) Promo Code (if applicable) Comments or Additional Information I wish to enroll in the Vision Plan of America Program. THIS CONTRACT IS FOR A MINIMUM OF 12 MONTHS from the effective date and renew at 12 month increments. I understand that all necessary services will be provided as described in the Evidence of Coverage. I hereby authorize Vision Plan of America or its designate to charge my credit card/checking account each month's applicable Dental and/or Vision premium to be credited to my account with Vision Plan of America. This authority is to remain in full force and effect until I notify Vision Plan of America in writing of my termination, thirty days thereafter Dental and/or Vision benefits will end. If the benefits are utilized the contract will remain in effect until the end of the term. This policy may be cancelled within three days of application with written notice to Vision Plan of America. * I agree to the above terms and conditions. A VPA service team member will contact you to complete the application. GET COVERED NOW GRIEVANCE FORM INDIVIDUALS GROUPS BROKERS PROVIDERS SEARCH CONTACT US Providers Click Here © 2018 Vision Plan of America