Dental and Vision Benefit Application

Name

First Name

Last Name

Status

Retired

Spouse

If Spouse or Surviving Spouse, Name of Clergy:

Address

City

State/Province

Zip/Postal

Retired Clergy Benefit

Dental Benefit ($250 per person per calendar year)

Vision Benefit ($250 per person per calendar year)

Please provide proof of an appointment, insurance, and/or bill for each Benefit you are applying for.

Date of Dental Appt.

Date of Vision Appt.

Spouse/Surviving Spouse Benefit

Dental Benefit ($250 per person per calendar year)

Vision Benefit ($250 per person per calendar year)

Please provide proof of an appointment, insurance, and/or bill for each Benefit you are applying for.

Date of Dental Appt.

Date of Vision Appt.

If you are human, leave this field blank.