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Boyle Brasher LLC
2016 Annual Enrollment
2016 Page 13
BOYLE BRASHER LLC
2016 DENTAL AND VOLUNTARY VISION ELECTION FORM
I, ________________________________, elect the following Anthem Dental and/or Vision plans
effective March 1, 2016.
______ I
DO
wish to make changes to my current enrollment elections.
______ I am
NOT
making any changes to my current enrollment elections.
DENTAL
VOLUNTARY VISION
COMPLETE PRIME (MAC)
BLUE VIEW VISION OPTION 59
Employee
_________
Employee
_________
Employee/Spouse
_________
Employee/Spouse _________
Employee/Child(ren)
_________
Employee/Child(ren) _________
Family
_________
Family
_________
Waive Coverage
_________
Waive Coverage
_________
It is important to note that if you waive coverage for yourself and/or dependents during this annual
enrollment you will not be able to enroll or make changes until next year unless you experience a
qualifying event.
I understand my above election will be in effect from March 1, 2016 through February 28, 2017.
Signature______________________________
Date____________________