Allegiance - Coordination of Benefits

Coordination of Benefits

Contact Info

Name

Phone

( ) - ×

Are you completing this COB form based on a letter you received? If so, please enter the Passcode from that letter here:

Do you have any health, dental, or vision coverage (including Medicare coverage) other than that provided by your Group?

Policy Holder's Other Coverage

Types of coverage (select all that apply)

Name of other insurance

Insurance company phone #

( ) - ×

Effective date of coverage

End date of coverage

Policy holder's name

Policy holder's ID #

Policy holder's date of birth

Is coverage a result of a court order?

Is this Medicare coverage?

List of individuals on this plan and relation to policy holder

Does your spouse have other health, dental, or vision coverage?

Spouse's Other Coverage

Types of coverage (select all that apply)

Name of other insurance

Insurance company phone #

( ) - ×

Effective date of coverage

End date of coverage

Policy holder's name

Policy holder's ID #

Policy holder's date of birth

Is coverage a result of a court order?

Is this Medicare coverage?

List of individuals on this plan and relation to policy holder

Is your spouse enrolling in Reid's dental or vision plans?

Types of coverage (select all that apply)

Name of other insurance

Insurance company phone #

( ) - ×

Effective date of coverage

End date of coverage

Policy holder's name

Policy holder's ID #

Policy holder's date of birth

Is coverage a result of a court order?

Is this Medicare coverage?

List of individuals on this plan and relation to policy holder

Additional Spouse Information

Are you enrolling your spouse on Reid's medical plan?

You will need to complete a Spousal Verification Form available on the Reid Human Resources Sharepoint site. Claims will not be processed until this form is returned to Human Resources.

Is your spouse employed?

Is your spouse self employed?

Is your spouse eligible for insurance through their employer?

Do your covered dependents have other health, dental, or vision coverage?

Dependent's Other Coverage

Types of coverage (select all that apply)

Name of other insurance

Insurance company phone #

( ) - ×

Effective date of coverage

End date of coverage

Policy holder's name

Policy holder's ID #

Policy holder's date of birth

Is coverage a result of a court order?

Is this Medicare coverage?

List of individuals on this plan and relation to policy holder

Do your covered dependents have any other health, dental, or vision coverage not already listed?

Dependent's Additional Other Coverage

Types of coverage (select all that apply)

Name of other insurance

Insurance company phone #

( ) - ×

Effective date of coverage

End date of coverage

Policy holder's name

Policy holder's ID #

Policy holder's date of birth

Is coverage a result of a court order?

Is this Medicare coverage?

List of individuals on this plan and relation to policy holder

May we contact you if additional information is required?

The Coordination of Benefits information is needed in order to process your claims accurately. If the requested information has not been received this may result in a delay and or denial of your claims.

Please do not hesitate to contact us if you have any questions.
Our Customer Service Team may be reached at 1-800-877-1122.

By submitting this information you are stating that the information, to the best of your knowledge, is correct.