CLAIM FORM FOR OPTICAL BENEFITS
WHEN COMPLETE
RETURN FORM TO: AGVA WELFARE TRUST FUND
363 Seventh Avenue – 17th Floor
New York, New York 10001-3904
(212) 627-4820


PERFORMER’S STATEMENT
(please print)



_____________________________________________________________________________________
LAST, FIRST, MI S.S. #

__________________________________________________________ __ __ __ - __ __ - __ __ __ __
MAILING ADDRESS

_____________________________________________________________________________________

Male ___ Female ___ DATE OF BIRTH –( MM-DD-YYYY) ___ ___ - ___ ___ -___ ___ ___ ___

PAID RECEIPTS FOR ALL SERVICES MUST BE ATTACHED. ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD OR DECEIVE ANY INSURANCE COMPANY AND/OR FILES A STATEMENT OF CLAIM CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION MAY BE GUILTY OF A CRIMINAL ACT PUNISHABLE UNDER LAW.

CERTIFICATE of OPTOMETRIST or OPHTHALMOLOGIST or OPTICIAN RENDERING SERVICES

I certify the above named patient was furnished the following services on the date(s) for which payment was received as indicated.

DATE OF____________________________________________________________________PAYMENT RECEIVED____________
EXAMINATION
$
________________________________________________________________________________________________________
LENSES
$
________________________________________________________________________________________________________
FRAMES
$
________________________________________________________________________________________________________


TOTAL RECEIVED: $_____________________________

Signature of Optometrist, Ophthalmologist or Optician (circle which on applies):


___________________________________________________________DATE: _______________EMP. ID #______________

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Performer is eligible for $200.00 for Plan A Coverage and $55.00 for Plan B Coverage, only once in each calendar year, for Examination, Lenses and/or Frames if expenses are incurred while the performer is ELIGIBLE for non-job related benefits in accordance with the eligibility rules of the AGVA Welfare Trust Fund Plan of benefits.
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TO BE COMPLETED BY WELFARE FUND OFFICE
DATE RECEIVED ELIGIBILITY CLAIM NO. CHECK NO. DATE PAYMENT COMMENTS_____________


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