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Vision Plan Enrollment Form

Open Enrollment Oct. 1 - Oct. 30

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I hereby apply for the vision benefit offered to me through VSP, for which I am eligible. I  understand that if I do not enroll within 30 days of my initial eligibility, then I will not be  able to obtain the benefit until the next open enrollment period. Open enrollment is  every October of each year. I understand that there is a two-year enrollment  requirement, which means that I must keep this coverage for a full two years, if I am still  employed with the agency.

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