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.