Income Attestation Form 2024 Plan Summary Trio HMO Payment MEC

Verbal BOR

Starts 10/1/23 thru 1/31/24

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CoveredCA Renewal FORM

Los Angeles - Orange County - San Diego - Riverside - Sacramento - And More!

Same Day Service!

Serving ALL of California Since 1998
949-713-7222

Need Help Renewing with CoveredCA.com?

Existing CC Clients

BOR

Open Enrollment 2024

Open Enrollment 2022

VPA B-1 Online Application

Spouse DOB:

Child 2 DOB:

Phone Number: *

ANNUAL RATES:

Individual $114
Invividual + 1 Dependent $195

Family $245

Click "Submit" to send your application in to Vision Plan of America via our SECURE SERVER. Your credit card will be charged within 1 - 7 business days. If you have any questions, please contact us at (949) 713-7222.

Who is Your Agent? *

WE HAVE NO COMPETITION!!
VSP annual rates for individuals & families have been known to be overpriced. These rates are as of 5+ years ago:

Individual - $181.95
Couple - $345.95
Family - $472.95

Have more questions? Call Toll Free (800) 400-4872

CREDIT CARD INFORMATION *

Child 3 Name:

Health insurance Plans

Meet Your Agent Marc Harris
Your Local Vision Plan of America Agent

I have been helping clients with VPA since 2001 and
have been very satisfied with the plan design,

customer service, and benefits for my clients.
I am on the plan for years, and the last time I went in to get my eye exam, frames and lenses, I walked out of my optometrist office with a $36 bill. That's it! This Vision Plan of America B-1 Plan is by far the best value plan on the market and I highly recommend that you give it a shot. If you are unhappy for any reason, contact VPA and opt-out after 12 months with absolutely NO QUESTIONS ASKED.

Interested in Health Insurance? We launched OE15.com to make it easy for clients like you evaluate all of your opportunities, and enroll in the policy with the best value. STOP waiting on hold for hours and START getting the service you deserve. Ready to renew your policy? We can help you today! Complete our short form and someone will contact you. COVERED CA RENEWAL FORM

Certified Insurance Agent: Marc Harris
Covered California Agent ID#: 2000016310
Date Certified: 10/29/2013
Certification #: 5000003622
PDF Download:Covered California Certificates
website: www.OE15.com
CA Insurance License #: 0C45052

MONTHLY RATES:

Individual $9.50
Individual + 1 Dependent $17.60
Family $22.40

Need the Provider Directory?
(Click Here)

MQ-2 Discount Plan
Available as low as $4 per month!

Print out the MQ-2 Hard Copy Application

Monthly Rates:

Individual - $4..00

Individual + 1 Dependent - $5.25

Family - $6.25

Annual Rates:

Individual - $55

Individual + 1 Dependent - $70

Family - $82

$10 ENROLLMENT FEE
A one-time non refundable $10.00 enrollment fee is included in the ANNUAL PREMIUM Only.

A one-time non refundable $10 enrollment fee will be added to your first month's fees if paid monthly.

Date of Birth (DD/MM/YYY): *

Card Number *

Complete Mailing Address *

Social Security XXX-XX-XXXX (Primary Applicant Only): *

How Your VPA Vision B-1 Plan Works
Vision Plan of America Helping all of CA Since 1986

Here are the benefits:

Annual Deductible: $10 Per Person
Eye Exam: Every 12 months 100% covered
Lenses: Every 12 months 100% covered
Frames: Every 24 months 100% covered (up to $100 Retail)
Cosmetic Contact Lenses: Every 12 months in addition to the basic benefit or, if desired, in lieu of the basic benefit, $100 applies to the doctor's usual and customary package fee.
Medically Necessary Contact Lenses: Every 24 months A $250 benefit

I wish to enroll in the Vision Plan of Americal Program VPA B-1. I understand that all necessary services will be provided as described in the Evidence of Coverage and this contract is for a minimum of 24 months *

I Agree

State: *

I live in California

I live outside CA

Referred By: *

Child 2 Name:

Vision Plan of America
B1 APPLICATION

24 Month Contract with
Opt-Out after 12 months

Have Questions? Call (949) 713-7222 or (800) 400-4872

Name (First and Last): *

Child 1 DOB:

Spouse Name:

VPA B-1 PAYMENT INFO (Check all that apply) *

PAY MONTHLY PREMIUM (Credit Card ACH)

$9.50 - Individual (B1)

$17.60 - Member + 1 Dependent (B1)

$22.40 - Family (B1)

PAY ANNUAL PREMIUM IN FULL

$114 - Individual (B1)

$195 - Member + 1 Dependent (B1)

$245 - Family (B1)

Name as it Appears on the Card *

Child 3 DOB:

Requested Effective Date (1st of month): *

Need the Provider Directory?
(Click Here)

Child 1 Name:

Email Address *

OPTOMETRIST CODE (Click the Blue Button to the right): *

Print Out an Application to Fax In

(Click Here)

Provider Directory - Schedule of Extras - B1 Online Brochure
B1 Online Application (Hard Copy) - Contact Lens Info

For more details visit: www.VisionPlanofAmerica.com

Expiration Date: *

Additional Notes

Open Enrollment 2022

Health insurance Plans

VISION