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Please refer “(Sample only)” for instruction.

1. Plan Election & Rate:
refer “(VISION) Plan Info & Rate”

2. Application: (First Choice) :
Fill out “(VISION) Application Form “

3.. Benefit
Employee (only) : 0% and ACI: 100%

4. Vision Benefit Declination
Fill out: “ (VISION) Insurance Declination Form (Decliner only) “

Thank you,
Wishing you and your family a very Merry Christmas and a Happy New Year !

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