Forms

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Employer-Sponsored

NRBT VSP

New Group Enrollment Forms

Employer Checklist

California

Universal EE Vision and Dental Application

Universal ER Vision and Dental Application

Colorado

Universal ER Vision Application

Universal EE Vision Application

Existing Group Forms

VSP Reimbursement Form

Termination Request Form

2016 Plan Benefit Summaries

English

Signature A $10

Signature A $25

Signature B $10

Signature B $25

Signature C $10

Signature C $25

Choice A $0

Choice B $0

Spanish

Signature A $10 Spanish

Signature A $25 Spanish

Signature B $10 Spanish

Signature B $25 Spanish

Signature C $10 Spanish

Signature C $25 Spanish

Choice A $0 Spanish

Choice B $0 Spanish

Additional Plan Offerings

VSP Extras – Additional Savings and Discounts

VSP Extras – TruHearing

Network Access Point Map

Network Providers – English & Spanish

VSP Extras – Polycarb lenses for kids

EOC

Signature A $10

Signature A $25

Signature B $10

Signature B $25

Signature C $10

Signature C $25

Choice A $0

Choice B $0

Individual

NRBT Ameritas

Rates & Benefit Summaries

Individual and Family Ameritas Enrollment Forms

Enrollment Checklist

Individual and Family Dental & Vision Application

Existing Plan Forms

Termination Request Form

Plan Benefit Summaries

Plan 1 – $1000 Annual Max $50 Ded

Plan 2 1250 Annual Max $50 Ded

Additional Plan Offerings

Ameritas Dental Rewards Program

NRBT VSP

Rates & Benefit Summaries

Individual and Family VSP Enrollment Forms

Enrollment Checklist

Individual and Family Vision Application

Plan Benefit Summaries

English

Signature Exam Plus

Choice Plan C $15 $0

Choice Plan B $15 $30

Choice Plan A $15 $30

Signature Plan B $15 CVC

Signature Plan B $15 $30 CVC

Signature Plan A $15 $30 CVC

Signature Plan B $15 $30

Signature Plan B $15

Signature Plan A $15 $30

Signature Plan A $15

Spanish

Signature Exam Plus – Spanish

Choice Plan C $15 $0 – Spanish

Choice Plan B $15 $30 – Spanish

Choice Plan A $15 $30 – Spanish

Signature Plan B $15 CVC – Spanish

Signature Plan B $15 $30 CVC – Spanish

Signature Plan A $15 $30 CVC – Spanish

Signature Plan B $15 $30 – Spanish

Signature Plan B $15 – Spanish

Signature Plan A $15 $30 – Spanish

Signature Plan A $15 – Spanish

Additional Plan Offerings

VSP Extras – Additional Savings and Discounts

Network Access Point Map

Network Providers – English & Spanish

VSP Extras – Polycarb lenses for kids

VSP Extras – TruHearing

EOC

Signature A $15

Signature A $15 $30

Signature B $15

Signature B $15 $30

Signature A $15 $30 CVC

Signature B $15 CVC

Signature B $15 $30 CVC

Choice A $15 $30

Choice B $15 $30

Choice C $15

Signature Exam Plus

Broker Tools

NRBT Agent Agreement

NRBT Agent Direct Deposit

NRBT Agent W9

NRBT Universal Contact Directory

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Voluntary

NRBT Ameritas Dental

Rates & Benefits Summaries

New Group Enrollment Forms

Employer Checklist

Universal ER Dental & Vision Application

Universal EE Dental & Vision Application

Existing Group Forms

Termination Request Form

ACH Authorization Form

Plan Benefit Summaries

Plan 1 – $1000 annual max $50 ded

Plan 2 – $1250 annual max $50 ded

Additional Plan Offerings

Ameritas Dental Rewards Program

EOC

Coming Soon

NRBT Delta Dental

Rates & Benefits Summary

New Group Enrollment Forms

Employer Checklist

Universal ER Dental & Vision Application

Universal EE Dental & Vision Application

Existing Group Forms

ACH Authorization Form

Termination Request Form

Plan Benefit Summaries

DeltaCare HMO

PPO Plan F

PPO Plan G

PPO Plan H

PPO Plan J

Premier Plan A

Premier Plan C

Premier Plan D

Premier Plan E

EOC

DeltaCare HMO

PPO Plan F

PPO Plan G

PPO Plan H

PPO Plan J

Premier Plan A

Premier Plan C

Premier Plan D

Premier Plan E

NRBT Humana

Rates & Benefit Summaries

New Group Enrollment Forms

Employer Checklist

Universal ER Dental & Vision Application

Universal EE Dental & Vision Application

Existing Group Forms

ACH Authorization Form

Termination Request Form

Plan Benefit Summaries

PPO Traditional Preferred

DHMO

PPO

PPO Preventive Plus

NRBT VSP

New Group Enrollment Forms

Employer Checklist

California

Universal EE Vision and Dental Application

Universal ER Vision and Dental Application

Colorado

Universal EE Vision Only Application

Universal ER Vision Application

Existing Group Forms

Termination Request Form

VSP Reimbursement Form

Plan Benefit Summaries

English

Signature Exam Plus

Signature A $15

Signature A $15/$30

Signature B $15

Signature B $15/$30

Signature A $15/$30 CVC

Signature B $15/$30 CVC

Signature B $15 CVC

Choice A $15 $30

Choice B $15/$30

Choice C $15

Spanish

Signature Exam Plus – Spanish

Signature A $15 – Spanish

Signature A $15/$30 – Spanish

Signature B $15 – Spanish

Signature B $15/$30 – Spanish

Signature A $15/$30 CVC – Spanish

SignatureB $15/$30 CVC – Spanish

Signature B $15 CVC – Spanish

Choice A $15/$30 – Spanish

Choice B $15/$30 – Spanish

Choice C $15 – Spanish

Additional Plan Offerings

VSP Extras – Additional Savings and Discounts

Network Access Point Map

Network Providers – English & Spanish

VSP Extras – Polycarb lenses for kids

VSP Extras – TruHearing

EOC

Signature Exam Plus

Signature A $15

Signature A $15 $30

Signature B $15

Signature B $15/$30

Signature A $15/$30 CVC

Signature B $15 CVC

Signature B $15/$30 CVC

Choice A $15/$30

Choice B $15/$30

Choice C $15

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