Assured Benefits Administrators Coordination of Benefits Form

Coordination of Benefits Form

Excel Health Plans
ASSURED BENEFITS ADMINISTRATORS
Please complete the form below in order to avoid delays in processing your claims and mail it to:

If you and your dependents are enrolled in another medical plan, please indicate below any other coverage. This would include coverage through an employer, a spouse's plan, a parent's plan, Medicaid, Medicare, etc.

If you have any questions, contact us at 1-800-247-7114. Our customer service representatives are available Monday through Friday from 8 a.m. to 6 p.m. Central Standard Time.
EMPLOYEE NAME*
EMPLOYER*
SSN*
PHONE*
EMAIL*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
DO YOU OR YOUR DEPENDENTS CURRENTLY HAVE ANY OTHER HEALTH INSURANCE COVERAGE?*

YesNo
If YES, provide the information requested below:
NAME OF COVERED PERSON (1)
OTHER INSURANCE CARRIER
ELIGIBILITY DATES
NAME OF COVERED PERSON (2)
OTHER INSURANCE CARRIER
ELIGIBILITY DATES
NAME OF COVERED PERSON (3)
OTHER INSURANCE CARRIER
ELIGIBILITY DATES
NAME OF COVERED PERSON (4)
OTHER INSURANCE CARRIER
ELIGIBILITY DATES
SIGNATURE*

Clear
PRINT NAME*
DATE*

MonthDayYear
Date
Should be Empty:

Coordination of Benefits Form