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Coordination of Benefits

If you have your explanation of benefits requesting COB information (i.e. your COB letter), please complete this form.

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1 Employee Information
2 Spouse / Dependent Information
3 Spouse / Dependent Employment Information
4 Authorization
Employee Information
Member IDEnter your Member ID
Claim # or Date(s) of ServiceEnter the Claim Number or Dates of Service
Full nameyour full name
Phone Number
Spouse/Dependent Information
Spouse's Full NameYour spouse's full name

Is Spouse Employed?

Spouse EmployedSpouse Employed
Spouse/Dependent Employment Information

Does your spouse have the ability to elect health insurance through their employer?

Spouse Employer Health InsuranceSpouse Employer Health Insurance

Does your spouse or any of your dependents have coverage through any other MEDICAL benefit plan?

Spouse Dependents Medical CoverageSpouse Dependents Medical Coverage
Other insurance plan nameOther insurance plan name

Does your spouse or any of your dependents have coverage through any other DENTAL benefit plan?

Spouse Dependents Dental CoverageSpouse Dependents Dental Coverage
Other insurance plan nameOther insurance plan name
Authorization
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