Group Name: Date:
Address:
City: State: Zip Code:

BROKER INFORMATION:
Name:  Email:
Address:
City: State: Zip Code:
Contact Phone:

Desired Group Effective Date :

Vision Plan Options
Value Vision Plan (annual eye exam and $150 materials allowance)
Elite Vision Plan (annual eye exam and $250 materials allowance)
Custom Vision Plan :

Broker Fee: $ per employee per month

Current Vision Insurance Carrier: