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VSP Open Enrollment - Confirmation

Congratulations! You have successfully completed the enrollment process. Your enrollment will be effective as of 01/01/2017. Please print this page for your records.

Your enrollment confirmation number is E9013161.

Enrollment Details
Enrollment Confirmation Number: First Name: Last Name: Last 4 of Member ID:
E9013161 JEFF BARTNER 6646

Enrollment Level: Date Of Birth: Gender:

Member + One 06/05/1951 MALE

Benefit Effective Date: Address: Address 2:

01/01/2017 308 MAYFIELD LN

Rate: City: State: Zip Code:

$25.61 MIDLAND MI 48640

Payment Method: Email Address: Phone Number:

CHECKING XXXX-9681 JEFFBARTNER@YAHOO.COM (989) 430-0224

Billing Frequency:
MONTHLY

Dependent information:

RELATIONSHIP FIRST NAME LAST NAME GENDER DATE OF BIRTH

SPOUSE CATHY BARTNER FEMALE 01/02/1952

Enrollment Terms
By accepting the enrollment terms, I agree that the information I provided in the enrollment form is true and accurate. I understand that I am enrolling in this voluntary group plan for a twelve
month period, unless there is an approved qualifying event. I authorize my enrollment information to be provided to the policy holder of the group into which I am seeking to enroll. I understand
that my initial and continuing enrollment is subject to the group?s approval. I understand my VSP plan will automatically renew unless I specifically elect not to renew.

https://www.vsp.com/prospective-member-confirmation-payment-enabled.html 11/7/2016