Printable Enrollment Form

Print the form below using your browser's "Print" button, complete it neatly and mail to the address below. Thank you for your interest in the Network Care Card vision plan!

Network Care Card Vision Enrollment Form
(Coast to Coast #44015)

Personal Information:

Last Name__________________________________________

First Name__________________________________________   Middle Initial____

Address____________________________________________

City__________________________________   State_______  Zip_______________

Social Security #__________-________-____________  (not required)

Date of Birth _______/_______/_______

Telephone # ( ________ ) ___________________________

Method of Payment:

Select One:
Annual Single Coverage = $29.50
Annual Family Membership = $39.50

Please indicate below how you would like to pay:
Check    Money Order    Visa    MasterCard    Discover    Amex

Cardholder Name_________________________________________

Credit Card Account #_____________________________________

Expiration Date___________/__________

Cardholder Signature______________________________________
I authorize Network Care Card/Coast to Coast Vision to charge the membership fee to the credit card listed above.

Signature (if different from Cardholder)_____________________________________

Date____________________________________________________

Make Checks Payable to:
Network Care Card

Mail Completed Application and Payment to:
Network Care Card
PO Box 545
Madison, NJ 07940-0545

© 2002 Broad Reach Benefits, Inc (4001)

Congratulations! You’re on your way to savings on your eyewear needs.

To enroll in the program complete the enrollment form, choose a payment method, and send the form with payment to Network Care Card at the above address.

Your order will be rapidly processed and your membership card, instructions and a provider listing will be sent directly to your home.

Please complete the form neatly so it is readable and doesn't slow up the processing of your order!

Two membership cards are provided and are good for the whole family. Additional cards are available for $2.50 each by calling the customer service number on your membership card.

We appreciate your business and know you will be very pleased with the benefits of the Network Care Card vision program.

© 2002 Broad Reach Benefits, Inc (4001)