Vision Plan Application Form

Vision Plan Coverage Options
If you are electing family coverage, enter below the names of spouse/domestic partner and/or children under 26 years of age. Adult children are covered to the end of the calendar year in which the child attains the age of 26. Unmarried children older than 26 years of age, who are incapable of self-support because of mental or physical disability, are covered if medical documentation of the disability is provided and upon approval from the Plan Administrator.

Payment Information

Note: Members who defraud or attempt to defraud the NYSUT Member Benefits Trust-endorsed Voluntary Vision Plan or who knowingly give false or misleading information are subject to a penalty, which may include suspension of eligibility for all Plan benefits. Members are responsible for notifying the Plan Office of any changes in marital and/or dependent status by submitting a Change of Status Card available from NYSUT Member Benefits Trust.

The Davis Vision Voluntary Vision Plan is a NYSUT Member Benefits Trust (Member Benefits)-endorsed program. Member Benefits has an endorsement arrangement of 8.5% of premium. All such payments to Member Benefits are used solely to defray the costs of administering its various programs and, where appropriate, to enhance them. Member Benefits acts as your advocate; please contact Member Benefits at 800-626-8101 if you experience a problem with any endorsed program.