Enrollment/Change Form 
Please print and complete all sections.  
See instructions below. 
Underwritten by Combined Insurance Company of America 
Group Number 
Client Name 
Location 
Code 
N/A 
Division 
Code 
N/A 
Client Co 
Code 
N/A 
Effective Date 
SUBSCRIBER  INFORMATION A: Add (enroll) 
Sex 
  M 
  F 
UVI – Employee ID 
Last Name (Subscriber) First Name 
M.I. 
Date of Birth 
Mailing  Address 
City/State/Zip 
Home Phone 
(         ) 
FAMILY INFORMATION (Only those eligible may be enrolled.) 
Add 
Sex 
  M 
  F 
Last Name (spouse) 
First Name 
M.I. 
Date of Birth 
Add 
Sex 
  M 
  F 
Last Name (dependent) 
First Name 
M.I. 
Date of Birth 
Add 
Sex 
  M 
  F 
Last Name (dependent) 
First Name 
M.I. 
Date of Birth 
Add 
Sex 
  M 
  F 
Last Name (dependent) 
First Name 
M.I. 
Date of Birth 
Add 
Sex 
  M 
  F 
Last Name (dependent) 
First Name 
M.I. 
Date of Birth 
Subscriber Signature: 
 Date:  
Instructions: 
Plan name:  Legal name of the plan. 
Group Number: Provided by EyeMed or EyeMed representative. 
Location code: N/A. 
Family Information: List only eligible family members who are 
enrolling. Dependent eligibility is the same as subscriber’s health plan. 
(A) Add: Open (group) enrollment or new (individual) enrollment during 
the contract period. 
(T) Terminate: To terminate enrollment. 
(C) Change: A change of name, address or phone. 
Your Authorization: 
I authorize payment for annual premium by payroll deduction: 
  $4.14    Per Subscriber only 
   $11.00  Per Subscriber + family 
Once you elect EyeMed vision coverage, you cannot cancel for a 12-month period based upon your enrollment date. 
Revised for University of the Virgin Islands Participants on 05/2016. 
SIGN