Dental and Vision Enrollment Form

Please fill out the following form to sign up for a American Payroll Insurance Services Dental and/or Vision plan.

Employee First Name: *

Employee Middle Name: *

Employee Last Name: *

Employee Home Street Address: *

City: *

State: *

Zip Code: *

Email: *

Date of Birth: *

mm/dd/yy

Sex: *

Agency Employed By: *

Home Phone: *

Work Phone:

Cell Phone:

Provider (Dentist) Number:

Find a dentist near you

DHSCalifornia Texas Florida

LibertyCalifornia Nevada

Choose Dental:

Plan Type:

Self

Self + one

Self + Family

Dependent Information

Last Name:

First Name:

M.I.:

Sex:

Date of Birth:

mm/dd/yy

Relationship:

Provider Number:

Last Name:

First Name:

M.I.:

Sex:

Date of Birth:

mm/dd/yy

Relationship:

Provider Number:

Last Name:

First Name:

M.I.:

Sex:

Date of Birth:

mm/dd/yy

Relationship:

Provider Number:

Last Name:

First Name:

M.I.:

Sex:

Date of Birth:

mm/dd/yy

Relationship:

Provider Number:

Vision Plan:

Plan Type:

Self

Self + one

Self + Family

Signature of Employee: *

Date: *