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NVI/NDN ENROLL 04/07 NJ VISION INSURANCE Underwritten by National Guardian Life Insurance Company Administered by: Superior Vision of New Jersey, Inc. 11090 White Rock Road Suite 175 Rancho Cordova, CA 95670 Enrollment / Change Form Please print and complete all sections. GROUP/EMPLOYEE INFORMATION A: Add (enroll) T: Terminate C: Change (change of name or coverage) Group Name Group Number Location Effective Date Date of Hire A T C Sex M F Last Name First Name M.I. Date of Birth Social Security Number Home Street Address City/State/Zip Home Phone ( ) Work Phone ( ) Email Address Cell Phone ( ) ELECTION(S) Employee Employee + Employee + Employee + Waived due to Waive Only Spouse Child(ren) Family other coverage FAMILY INFORMATION (Only those eligible may be enrolled.) A: Add (enroll) T: Terminate C: Change (change of name or coverage) A T C Sex M F Last Name (spouse) First Name M.I. Date of Birth A T C Sex M F Last Name (dependent) First Name M.I. Date of Birth Child unmarried and full-time student or handicapped? Yes No A T C Sex M F Last Name (dependent) First Name M.I. Date of Birth Yes No A T C Sex M F Last Name (dependent) First Name M.I. Date of Birth Yes No A T C Sex M F Last Name (dependent) First Name M.I. Date of Birth Yes No A T C Sex M F Last Name (dependent) First Name M.I. Date of Birth Yes No A T C Sex M F Last Name (dependent) First Name M.I. Date of Birth Yes No Employee Signature: ___________________________________________________ Date: __________________ Do you or any of your dependents have other vision insurance? Yes No If yes, please give: Policyholder and Insurance Company . Declination of coverage must be accompanied by the Employee’s signature above. ANY PERSON WHO INCLUDES ANY FALSE OR MISLEADING INFORMATION ON AN APPLICATION FOR AN INSURANCE POLICY IS SUBJECT TO CRIMINAL AND CIVIL PENALTIES.