Coordination of Benefits verification

Part I: Employee Information

Group ID *
Claim # * **
Name *
Contact ***
* Refer to your Coordination of Benefits (COB) form
** If you received multiple COB forms, it is only necessary to complete this information once
*** A phone or email to contact you should more information be required

Part II: Spouse/Dependent Information

Name
Is spouse employed?

Part III: Spouse/Dependent Employment Information

Does your spouse have the ability to elect health insurance through their employer?
Does your spouse or any of your dependents have coverage through any other MEDICAL benefit plan?
Other insurance plan name
Does your spouse or any of your dependents have coverage through any other DENTAL benefit plan?
Other insurance plan name

Part IV: Authorization

I affirm that the information submitted is accurate to the best of my knowledge and represents my current benefits situation.
I agree
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