Coordination of Benefits & Information Verification Form

  • COORDINATION OF BENEFITS & INFORMATION VERIFICATION FORM

    PLEASE NOTE: OTHER BUSINESS PARTNERS WILL ALSO REQUEST THIS INFORMATION SEPARATELY.

  • PARTICIPANT INFORMATION

  • Date of Birth*
     / /
  • Gender*
  • Marital Status*
  • Date of Divorce*
     / /
  • Check the following languages in which you are literate*
  • Are you a policyholder of any other group medical, vision or dental plan other than Medicare?*
  • Does the Plan Cover Dependents?*
  • Status for Plan Coverage*
  • Does the Plan Follow the Birthday Rule?
  • Benefits Provided*
  • Effective Date of Coverage*
     / /
  • Does the Other Coverage have a Termination Date?*
  • Termination Date*
     / /
  • Are you entitled to Medicare Part A or B? If yes, submit a copy of your Medicare Card if it has not been previously submitted.*
  • NEXT STEP: Are you providing dependent information?*

  • DEPENDENT INFORMATION & DECLARATION OF COVERAGE

  • List all eligible dependents to be covered, including your spouse. All dependents currently covered on the Fund’s Plan MUST be listed and all requested information must be provided. If this Form is incomplete additional information will be requested.

    If you are adding a new spouse or dependent child to your coverage, please submit the below documentation.  Souvenir copies are not accepted.

    Spouse – copy of county filed marriage certificate

    Child – copy of state issued birth certificate; or if you or your spouse are divorced submit a copy of the divorce decree and any settlement agreement stating custody and medical responsibility for the child.  The decree must be signed and dated by the judge

    If either you or your spouse are divorced and you are adding a child or stepchild, submit a copy of the divorce decree and any settlement agreement made part of the decree stating custody and medical responsibility for the children. The decree must be signed and dated by the judge.

  • Do you have a spouse covered under this Plan, or are you adding a new spouse to this Plan?*

  • SPOUSAL INFORMATION

  • Date of Birth*
     / /
  • Gender*
  • Is your spouse offered group health coverage through his/her employer (whether they have accepted the other coverage or not)?*
  • Does this person have other group medical, vision, prescription or dental coverage? (including Medicare)*
  • Does the Plan Cover Dependents?*
  • Status for Plan Coverage*
  • Does the Plan Follow the Birthday Rule?
  • Benefits Provided*
  • Effective Date of Coverage*
     / /
  • Does the Other Coverage have a Termination Date?*
  • Termination Date*
     / /
  • Is there any additional insurance coverage?*
  • Does the Plan Cover Dependents?*
  • Status for Plan Coverage*
  • Does the Plan Follow the Birthday Rule?
  • Benefits Provided*
  • Effective Date of Coverage*
     / /
  • Does the Other Coverage have a Termination Date?*
  • Termination Date*
     / /
  • NEXT STEP: Do you have additional dependents to add?*

  • DEPENDENT INFORMATION #1

  • Date of Birth*
     / /
  • Gender*
  • Is this dependent a child or stepchild with divorced parents?*
  • Does the child live in the Participant's home?*
  • Does this person have other group medical, vision, prescription or dental coverage? (including Medicare)*
  • Does the Plan Cover Dependents?*
  • Status for Plan Coverage*
  • Does the Plan Follow the Birthday Rule?
  • Benefits Provided*
  • Effective Date of Coverage*
     / /
  • Does the Other Coverage have a Termination Date?*
  • Termination Date*
     / /
  • NEXT STEP: Would you like to add another dependent?*

  • DEPENDENT INFORMATION #2

  • Date of Birth*
     / /
  • Gender*
  • Is this dependent a child or stepchild with divorced parents?*
  • Does the child live in the Participant's home?*
  • Does this person have other group medical, vision, prescription or dental coverage? (including Medicare)*
  • Does the Plan Cover Dependents?*
  • Status for Plan Coverage*
  • Does the Plan Follow the Birthday Rule?
  • Benefits Provided*
  • Effective Date of Coverage*
     / /
  • Does the Other Coverage have a Termination Date?*
  • Termination Date*
     / /
  • NEXT STEP: Would you like to add another dependent?*

  • DEPENDENT INFORMATION #3

  • Date of Birth*
     / /
  • Gender*
  • Is this dependent a child or stepchild with divorced parents?*
  • Does the child live in the Participant's home?*
  • Does this person have other group medical, vision, prescription or dental coverage? (including Medicare)*
  • Does the Plan Cover Dependents?*
  • Status for Plan Coverage*
  • Does the Plan Follow the Birthday Rule?
  • Benefits Provided*
  • Effective Date of Coverage*
     / /
  • Does the Other Coverage have a Termination Date?*
  • Termination Date*
     / /
  • NEXT STEP: Would you like to add another dependent?*

  • DEPENDENT INFORMATION #4

  • Date of Birth*
     / /
  • Gender*
  • Is this dependent a child or stepchild with divorced parents?*
  • Does the child live in the Participant's home?*
  • Does this person have other group medical, vision, prescription or dental coverage? (including Medicare)*
  • Does the Plan Cover Dependents?*
  • Status for Plan Coverage*
  • Does the Plan Follow the Birthday Rule?
  • Benefits Provided*
  • Effective Date of Coverage*
     / /
  • Does the Other Coverage have a Termination Date?*
  • Termination Date*
     / /
  • NEXT STEP: Would you like to add another dependent?*

  • DEPENDENT INFORMATION #5

  • Date of Birth*
     / /
  • Gender*
  • Is this dependent a child or stepchild with divorced parents?*
  • Does the child live in the Participant's home?*
  • Does this person have other group medical, vision, prescription or dental coverage? (including Medicare)*
  • Does the Plan Cover Dependents?*
  • Status for Plan Coverage*
  • Does the Plan Follow the Birthday Rule?
  • Benefits Provided*
  • Effective Date of Coverage*
     / /
  • Does the Other Coverage have a Termination Date?*
  • Termination Date*
     / /
  • NEXT STEP: Would you like to add another dependent?*

  • DEPENDENT INFORMATION #6

  • Date of Birth*
     / /
  • Gender*
  • Is this dependent a child or stepchild with divorced parents?*
  • Does the child live in the Participant's home?*
  • Does this person have other group medical, vision, prescription or dental coverage? (including Medicare)*
  • Does the Plan Cover Dependents?*
  • Status for Plan Coverage*
  • Does the Plan Follow the Birthday Rule?
  • Benefits Provided*
  • Effective Date of Coverage*
     / /
  • Does the Other Coverage have a Termination Date?*
  • Termination Date*
     / /
  • NEXT STEP: Would you like to add another dependent?*

  • DEPENDENT INFORMATION #7

  • Date of Birth*
     / /
  • Gender*
  • Is this dependent a child or stepchild with divorced parents?*
  • Does the child live in the Participant's home?*
  • Does this person have other group medical, vision, prescription or dental coverage? (including Medicare)*
  • Does the Plan Cover Dependents?*
  • Status for Plan Coverage*
  • Does the Plan Follow the Birthday Rule?
  • Benefits Provided*
  • Effective Date of Coverage*
     / /
  • Does the Other Coverage have a Termination Date?*
  • Termination Date*
     / /
  • NEXT STEP: Would you like to add another dependent?*

  • DEPENDENT INFORMATION #8

  • Date of Birth*
     / /
  • Gender*
  • Is this dependent a child or stepchild with divorced parents?*
  • Does the child live in the Participant's home?*
  • Does this person have other group medical, vision, prescription or dental coverage? (including Medicare)*
  • Does the Plan Cover Dependents?*
  • Status for Plan Coverage*
  • Does the Plan Follow the Birthday Rule?
  • Benefits Provided*
  • Effective Date of Coverage*
     / /
  • Does the Other Coverage have a Termination Date?*
  • Termination Date*
     / /
  • NEXT STEP: Would you like to add another dependent?*

  • DEPENDENT INFORMATION #9

  • Date of Birth*
     / /
  • Gender*
  • Is this dependent a child or stepchild with divorced parents?*
  • Does the child live in the Participant's home?*
  • Does this person have other group medical, vision, prescription or dental coverage? (including Medicare)*
  • Does the Plan Cover Dependents?*
  • Status for Plan Coverage*
  • Does the Plan Follow the Birthday Rule?
  • Benefits Provided*
  • Effective Date of Coverage*
     / /
  • Does the Other Coverage have a Termination Date?*
  • Termination Date*
     / /
  • NEXT STEP: Would you like to add another dependent?*

  • DEPENDENT INFORMATION #10

  • Date of Birth*
     / /
  • Gender*
  • Is this dependent a child or stepchild with divorced parents?*
  • Does the child live in the Participant's home?*
  • Does this person have other group medical, vision, prescription or dental coverage? (including Medicare)*
  • Does the Plan Cover Dependents?*
  • Status for Plan Coverage*
  • Does the Plan Follow the Birthday Rule?
  • Benefits Provided*
  • Effective Date of Coverage*
     / /
  • Does the Other Coverage have a Termination Date?*
  • Termination Date*
     / /
  • NEXT STEP: Would you like to add another dependent?*

  • If you would like to add more than ten (10) dependents please contact the Fund Office.

    Boilermakers National Health and Welfare Fund
    PO Box 909700
    Kansas City, MO 64190-9700

    Email: bnf@wilson-mcshane.com

    Phone: (866) 342-6555 or (913) 342-6555

  • If you have not previously submitted documents for a new dependent spouse or child, please send required documents to:

    Boilermakers National Health and Welfare Fund
    PO Box 909700
    Kansas City, MO 64190-9700

    Fax: (913) 281-7915

    Email: bnf@wilson-mcshane.com

    Questions? Contact the Fund Office at: (866) 342-6555 or (913) 342-6555

    I understand that if I or my dependents provide false information to the Boilermakers National Health & Welfare Fund or conceal information we could be subject to severe penalties under state and federal law and the Fund may seek to recover benefits wrongfully paid or pursue legal remedies against us. I declare under penalty of perjury that the foregoing is true and correct.

    I agree, for myself and my dependents, that in the event any health services provided are the primary responsibility of any other party by way of other group health coverage or by the act of omission of another person to fully inform Boilermaker's National Health and Welfare Fund and that will execute such assignments. liens or other documents which maybe necessary to enable Boilermaker's National Health and Welfare Funds to recover the value of benefits provided further agree that in the event or any of my dependents collect benefits or damages from any other party who has primary responsibility for services provided. I will immediately reimburse Boilermaker's National Health and Welfare Funds to the extent of services provided and to the extent as specified by the plan.

    FRAUD WARNING: Any person who, knowingly and with intent to defraud the Fund or other person: (1) files an application for benefits or statement of claim containing any materially false information: or (2) conceals for the purpose of misleading information concerning any material fact thereto, commits, a fraudulent act and may be subject legal action.

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