Tear Along Dotted Line
Superior Vision Coverage
Enrollment Form
North Carolina
Retired
Governmental
Employees’
Association
4 ways to enroll
1. Online Self Enrollment Portal at markiiieb.com/enroll
2. Call Center Enrollment with Mark III Employee Benefits toll-free 833-444-5220
3. Online Form Submission through the NCRGEA Website www.ncrgea.com
4. Mail application in enclosed envelope to NCRGEA, 528 Wade Ave, Raleigh, NC 27605, or fax application to 919-834-4622
Please complete all information to enroll.
Questions regarding the Superior Vision insurance plan or NCRGEA dues, please call the Mark III call center at 833-444-5220.
Retiree Information
Social Security #__________-________-____________ Date of Birth________/________/________ Sex M P F P
Last Name_________________________________________ First Name________________________________ MI __________
Street Address____________________________________________________________________________________________
City________________________________________________________ State__________ Zip Code ______________________
Cell Phone (________)_____________________________ Land Line Phone (________) ______________________________
Email Address ____________________________________________________________________________________________
Type of Coverage P Retiree only $6.99 / Month P Retiree and Family $15.88 / Month
YOUR COVERAGE
To ADD DEPENDENTS, fill out this section.
Spouse Name: __________________________________________________________ Date of Birth_____________________
Child Name: __________________________________________________________ Date of Birth_____________________
Child Name: __________________________________________________________ Date of Birth_____________________
Child Name: __________________________________________________________ Date of Birth_____________________
Retirement Payroll Deduction Authorization (this section must be signed to receive benefits)
I hereby authorize the North Carolina Retirement System to deduct from my retirement account, both my NCRGEA
membership dues and my vision plan premiums. If your NCRGEA membership dues have been paid for the current year, we
will begin your dues deduction the month prior to your next scheduled renewal date. Dues are based on monthly income
(see enclosed membership enrollment card for the scale). This authorization applies to such coverage until I rescind it in
writing. My annual dues are: P $15.00 ($1.25 monthly) P $25.00 ($2.09 monthly) P $40.00 ($3.34 monthly)
Signature _____________________________________________________ Date ________________________________
EF-V-01-Bk
Important: Complete the reverse side
/enroll
/www.ncrgea.com