Coordination of Benefits (COB) Form

Coordination of Benefits

In order to accurately process your benefits, we must keep our records up to date. To avoid any delay in the processing of claims, please provide us with the following information.
Employee Name*

First NameLast Name
Date*

MonthDayYear
Date
Emplyee ID
Are you, your spouse/partner and/or dependent(s) enrolled in any other health coverage?*

YESNO
List yourself & family members, who are enrolled on other health coverage?*

First NameLast Name
Relationship*
Name of Custodial Parent(s) of dependent children above*

First NameLast Name
If applicable, please attach a copy of any court documentation pertaining to custody and/or medical coverage responsibility

Cancelof
Do you need to add other family members enrolled in health coverage?*

YESNO
List yourself & family members, who are enrolled on other health coverage?*

First NameLast Name
Relationship*
Name of Custodial Parent(s) of dependent children above*

First NameLast Name
If applicable, please attach a copy of any court documentation pertaining to custody and/or medical coverage responsibility

Cancelof
Do you need to add other family members enrolled in health coverage?*

YESNO
List yourself & family members, who are enrolled on other health coverage?*

First NameLast Name
Relationship*
Name of Custodial Parent(s) of dependent children above*

First NameLast Name
If applicable, please attach a copy of any court documentation pertaining to custody and/or medical coverage responsibility

Cancelof
Do you need to add other family members enrolled in health coverage?*

YESNO
List yourself & family members, who are enrolled on other health coverage?*

First NameLast Name
Relationship*
Name of Custodial Parent(s) of dependent children above*

First NameLast Name
If applicable, please attach a copy of any court documentation pertaining to custody and/or medical coverage responsibility

Cancelof
Do you need to add other family members enrolled in health coverage?*

YESNO
List yourself & family members, who are enrolled on other health coverage?*

First NameLast Name
Relationship*
Name of Custodial Parent(s) of dependent children above*

First NameLast Name
If applicable, please attach a copy of any court documentation pertaining to custody and/or medical coverage responsibility

Cancelof
Do you need to add other family members enrolled in health coverage?*

YESNO
List yourself & family members, who are enrolled on other health coverage?*

First NameLast Name
Relationship*
Name of Custodial Parent(s) of dependent children above*

First NameLast Name
If applicable, please attach a copy of any court documentation pertaining to custody and/or medical coverage responsibility

Cancelof
Do you need to add other family members enrolled in health coverage?*

YESNO
List yourself & family members, who are enrolled on other health coverage?*

First NameLast Name
Relationship*
Name of Custodial Parent(s) of dependent children above*

First NameLast Name
If applicable, please attach a copy of any court documentation pertaining to custody and/or medical coverage responsibility

Cancelof
Other coverage includes:*

Medical / RxDentalVision
Policy Holder*

First NameLast Name
Policy/Certificate #*
Date of Birth*

MonthDayYear
Date
Effective Date*

MonthDayYear
Date
Covered End Date (if applicable)

MonthDayYear
Date
Name of other insurance provider*
Address of insurance company*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you or any of your dependents are enrolled on:*

MedicaidMedicareNo
Enrollee's Name*

First NameLast Name
ID Number*
Medicaid Effective Date

MonthDayYear
Date
Part A Effective Date

MonthDayYear
Date
Part B Effective Date

MonthDayYear
Date
Part D Effective Date

MonthDayYear
Date
Reason for Medicare entitlement:*

AgeDisabilityESRD (End Stage Renal Disease)ESRD & Disability
ESRD onset Date (if Applicable)

MonthDayYear
Date
Do you need to add other dependents are enrolled on:*

MedicaidMedicareNo
Enrollee's Name*

First NameLast Name
ID Number*
Medicaid Effective Date

MonthDayYear
Date
Part A Effective Date

MonthDayYear
Date
Part B Effective Date

MonthDayYear
Date
Part D Effective Date

MonthDayYear
Date
Reason for Medicare entitlement:*

AgeDisabilityESRD (End Stage Renal Disease)ESRD & Disability
ESRD onset Date (if Applicable)

MonthDayYear
Date
Do you need to add other dependents are enrolled on:*

MedicaidMedicareNo
Enrollee's Name*

First NameLast Name
ID Number*
Medicaid Effective Date

MonthDayYear
Date
Part A Effective Date

MonthDayYear
Date
Part B Effective Date

MonthDayYear
Date
Part D Effective Date

MonthDayYear
Date
Reason for Medicare entitlement:*

AgeDisabilityESRD (End Stage Renal Disease)ESRD & Disability
ESRD onset Date (if Applicable)

MonthDayYear
Date
Do you need to add other dependents are enrolled on:*

MedicaidMedicareNo
Enrollee's Name*

First NameLast Name
ID Number*
Medicaid Effective Date

MonthDayYear
Date
Part A Effective Date

MonthDayYear
Date
Part B Effective Date

MonthDayYear
Date
Part D Effective Date

MonthDayYear
Date
Reason for Medicare entitlement:*

AgeDisabilityESRD (End Stage Renal Disease)ESRD & Disability
ESRD onset Date (if Applicable)

MonthDayYear
Date
Do you need to add other dependents are enrolled on:*

MedicaidMedicareNo
Enrollee's Name*

First NameLast Name
ID Number*
Medicaid Effective Date

MonthDayYear
Date
Part A Effective Date

MonthDayYear
Date
Part B Effective Date

MonthDayYear
Date
Part D Effective Date

MonthDayYear
Date
Reason for Medicare entitlement:*

AgeDisabilityESRD (End Stage Renal Disease)ESRD & Disability
ESRD onset Date (if Applicable)

MonthDayYear
Date
Do you need to add other dependents are enrolled on:*

MedicaidMedicareNo
Enrollee's Name*

First NameLast Name
ID Number*
Medicaid Effective Date

MonthDayYear
Date
Part A Effective Date

MonthDayYear
Date
Part B Effective Date

MonthDayYear
Date
Part D Effective Date

MonthDayYear
Date
Reason for Medicare entitlement:*

AgeDisabilityESRD (End Stage Renal Disease)ESRD & Disability
ESRD onset Date (if Applicable)

MonthDayYear
Date
Please review your responses carefully before signing and submitting this form.
Please verify that you are human*
Signature*

Clear
If you have any questions, please contact our customer service department at 877-585-8480.

PO Box 450978 | Westlake, OH 44145 | 877-585-8480
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