COORDINATION OF BENEFITS

Please complete the information below.  If you have any quesions regarding this form, please contact your Insurance Company Customer Service at the numnber on the participant's medical card.
 
Your policy contains a "coordination of benefits" provision that allows Your Insurance  to share responsibility in covering heath care expenses with any other company covering your or your family for meidcal benefits. When health care expenses are shared between two or more companies, out-of-pocket expenses fo the participants may be reduced.  In addition to benefitting the indicidual member, coordination of benefits is beneficial to all participants because it avoids duplicaiton of payments that would result in higher premium reates.

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If married, please complete the following:


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Is spouse covered under his/her employer's health plan?

If yes, please complete the following
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If you are divorced and/or remarried with dependents, please complete the following


 DependentsPerson with Physical CustodyRelationshipPerson Responsible for Dependent Health Care Expenses per Divorce Decree
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If you or your family member are covered under any other medical/dental plan in addition to the coverage listed above (i.e., Medicare or Medicaid, other insurance), please complete the following section. (This does not include the employee's current insurance plan.)
 Health Plan NameName of Person CoveredPolicy NumberEffective Date
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