Insurance Form

Complimentary Shipping on Orders Over* $55

INSURANCE REIMBURSEMENT FORM

Do you currently have Vision Insurance? Many insurance companies offer reimbursement for out-of-network purchases. We’re happy to help you with this process using the form below. Once you’ve completed the form, we’re able to tell you how much you are eligible to receive as reimbursement. After you’ve completed your reading glasses purchase on americansunandreader.com, we submit your claim and you are good to go!

Fill out the form below to receive an insurance quote.

First Name *(Required)

Last Name *(Required)

Email *(Required)

Phone *(Required)

Full Address *(Required)

Birthday *(Required)

Sex *(Required)

Choose Your Vision Plan (Unfortunately if your plan is not listed we are unable to submit for reimbursement on your behalf) *(Required)

Primary Insured's First Name *(Required)

Relationship to Primary Insured *(Required)

Last FOUR Digits of the Primary's Social Security Number *(Required)

Employer or Group Number(Required)

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Complimentary Shipping on Orders Over* $55

Complimentary Shipping on Orders Over* $55

INSURANCE REIMBURSEMENT FORM

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