Avesis - Vision Enrollment/Cancellation Form - Black Hawk County - co black-hawk ia 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your Employee Name, Date of Birth, and Social Security Number. Ensure all information is printed legibly for clarity.
3. Fill in your Address, City, State, and Zip Code accurately to avoid any issues with communication.
4. Indicate your sex by selecting either Male or Female. This is a required field.
5. Under Employer Group Name, enter 'Black Hawk County' as specified.
6. Decide if you wish to cover eligible Dependents by selecting Yes or No. If Yes, provide the names and dates of birth for each dependent.
7. Authorize deductions from your earnings by signing and dating the form at the bottom. This confirms your eligibility and agreement to participate.
8. Select whether this is a New Enrollment, Cancel Coverage, or Add/Change information. Provide any necessary details regarding changes.

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