Vision Plan Forms

This page provides a description of and links to National IAM Benefit Trust Fund forms related to Fund vision plans. Click the form titles below to review or download copies.

Enrollment Form

Enrollment Form (PDF)

Eligible employees may enroll in a National IAM Benefit Trust Fund vision plan by completing and submitting this form. This form is also used to enroll eligible dependents.

Disabled Dependent Certification Form

Disabled Dependent Certification Form (PDF)

Eligible employees wishing to designate an eligible disabled dependent must complete and submit this form in addition to the enrollment form. The Physician Certification of Disability Form must be completed by both the employee and the dependent's attending physician.

Eligible Dependent Certification Form

Eligible Dependent Certification Form (PDF)

Eligible employees who designate eligible dependents who are not the employees' biological children, or who have a different last name from the employee, must certify the dependent's eligibility for coverage by completing and submitting this form in addition to the enrollment form.

Waiver Form

Waiver Form (PDF)

Eligible employees wishing to waive coverage must complete and submit this form.

EyeMed Out of Network Form

Out of Network Form (PDF)

Eligible employees wishing to submit an out of network claim must complete and submit this form.

EyeMed Out of Network Instructions

Out of Network Instructions (PDF)

Eligible employees wishing to submit an out of network claim must follow these steps.

EyeMed Online Options

EyeMed Online Options (PDF)

Eligible employees may use the following online resources when pursuing in-network options.