Vision Application

Templates

Vision Application

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Insurance

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Datapoint

Description

This is some text inside of a div block.

Applicant Full Name

Legal name of the individual applying for vision coverage.

Date of Birth

Used to determine age-based eligibility and rating.

Mailing Address

Primary address of the applicant, including street, city, state, and ZIP code.

Phone Number

Contact number for communication regarding enrollment.

Email Address

Email address for correspondence and policy documents.

Social Security Number (SSN) or Member ID

Used for identity verification and processing eligibility.

Employer Name

Identifies the applicant’s employer if applying through a workplace-sponsored plan.

Plan Selection

Name or tier of the selected vision insurance plan, if known or pre-selected.

Coverage Type

Specifies if the application is for individual, employee + spouse, employee + children, or family coverage.

Requested Effective Date

Date on which the applicant wishes coverage to begin.

Dependent Information (if applicable)

Names, dates of birth, and relationships of any dependents to be covered under the plan.

Routine Eye Exam Coverage

Acknowledgment that coverage is requested for annual or biennial eye exams.

Lenses Coverage

Confirmation that prescription lenses are included in the desired coverage.

Frames Coverage

Indicates interest in eyeglass frame benefits (typically reimbursed on a 12- or 24-month cycle).

Contact Lenses Coverage

Optional field for applicants preferring or supplementing glasses with contact lenses.

Out-of-Network Reimbursement

Indicates whether the applicant wants coverage to include out-of-network providers, if available.

Prior Vision Insurance

Captures whether the applicant had vision coverage in the last 12 months and with which carrier.

Eligibility Confirmation

Applicant attestation that they meet all eligibility requirements (e.g., residency, group participation).

A vision insurance application collects essential applicant and coverage details to set up vision care benefits. It includes personal information such as the applicant’s full name, date of birth, mailing address, phone number, email, and SSN or member ID, along with employer details if the plan is workplace-sponsored. The form also captures requested coverage type, plan selection, effective date, and dependent information when applicable.

Feathery’s AI extracts data on selected benefits such as routine eye exams, prescription lenses, frames, and contact lenses, as well as options for out-of-network reimbursement. It also identifies prior vision coverage, eligibility attestations, and any supplemental plan details. Automating this process reduces manual entry, ensures accurate enrollment, and accelerates eligibility verification and benefits activation for vision insurance applicants.

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