Our old policy: Carrier/policy name Policy numberGroup number Policy holder name Policy holder DOB Policy holder SSN Our new policy: Carrier/policy name Policy number Group numberPolicy holder namePolicy holder DOBPolicy holder SSNOur secondary policy (if any):Carrier/policy namePolicy numberGroup numberPolicy holder namePolicy holder DOBPolicy holder SSN
To the best of my knowledge the information above is true and correct. If there are any denials of coverage as a result of the information given above, I agree to accept full financial responsibility.