EyeMed

Personal Information

Please provide the following infromation to enroll.  If you were enrolled with Avesis last year and wish to move your coverage to Eyemed, please select "Coverage Change" for Enrollment Status.  This will let us know to remove your previous coverage selections and replace it with the information you provide below.

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Applicant Information

Enrollment Status * Please make a selection
Department Number * Required
Payroll Number (no dashes) * Required
First Name * Required
Middle Initial
Last Name * Required
SSN * Please enter a valid SSN ###-##-####
Birth Date * Please enter a valid date MM/DD/YYYY
Sex * Required
Marital Status
(Spouse or Domestic Partner)
Thank you
Street Address Line 1 * Required
Street Address Line 2
City * Required
State * Required
Zip * Please enter a valid zip code
Phone * Please enter a valid phone number ### ### ####
Email Address
Number of Covered Dependents
(Not including Spouse)
Thank you

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