Coordination of Benefits / Spousal Verification Form

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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.
Please do not hesitate to contact us if you have any questions.
Our Customer Service Team may be reached at 1-855-999-0295.
By submitting this information you are stating that the information, to the best of your knowledge, is correct.