Member Coordination of Benefit (COB) Form
EMPLOYEE NAME
*
DATE OF BIRTH
*
/
Month
/
Day
Year
Date
SSN
*
EMPLOYEE MAILING ADDRESS
*
EMPLOYEE CONTACT NUMBER
*
EMPLOYEE EMAIL ADDRESS
example@example.com
DO YOU HAVE OTHER HEALTH COVERAGE?
YES
NO
TYPE OF COVERAGE
MEDICAL
DENTAL
DRUG
NAME OF CARRIER
MEMBER ID NUMBER
*
EFFECTIVE DATE
*
/
Month
/
Day
Year
Date
ARE YOU COVERED BY MEDICARE?
*
Yes
No
WHAT IS YOUR MEDICARE NUMBER
PART A EFFECTIVE DATE
/
Month
/
Day
Year
Date
PART B EFFECTIVE DATE
/
Month
/
Day
Year
Date
PART D EFFECTIVE DATE
/
Month
/
Day
Year
Date
DISABILITY/ESRD EFFECTIVE DATE
/
Month
/
Day
Year
Date
IF YOUR SPOUSE IS CURRENTLY COVERED UNDER YOUR NETCARE POLICY, PLEASE COMPLETE THE FOLLOWING:
IF YOU DO NOT HAVE A SPOUSE OR IF YOUR SPOUSE DOES NOT HAVE ANY COVERAGE, PLEASE CHECK HERE TO CONTINUE.
SPOUSE NAME
*
SPOUSE DATE OF BIRTH
*
/
Month
/
Day
Year
Date
SPOUSE SSN
DOES YOUR SPOUSE HAVE OTHER COVERAGE?
*
YES
NO
IS YOUR SPOUSE COVERED THROUGH AN EMPLOYER?
YES
NO
IS YOUR SPOUSE RETIRED?
*
YES
NO
PLEASE PROVIDE EMPLOYER NAME & ADDRESS THAT PROVIDES GROUP HEALTH COVERAGE FOR YOUR SPOUSE:
EMPLOYER NAME
EMPLOYER ADDRESS
IS YOUR SPOUSE COVERED AS A DEPENDENT UNDER ANOTHER POLICY?
*
YES
NO
IF YES, NAME OF PERSON WHO COVERS YOUR SPOUSE AS A DEPENDENT:
TYPE OF COVERAGE
MEDICAL
DENTAL
DRUG
NAME OF CARRIER
MEMBER ID NUMBER
EFFECTIVE DATE
/
Month
/
Day
Year
Date
DOES YOUR SPOUSE'S COVERAGE EXTEND TO YOUR DEPENDENT CHILDREN'?
*
YES
NO
IS YOUR SPOUSE COVERED BY MEDICARE?
*
YES
NO
IF YES, WHAT IS THE MEDICARE NUMBER:
PART A
/
Month
/
Day
Year
EFFECTIVE DATE
PART B
/
Month
/
Day
Year
EFFECTIVE DATE
PART D
/
Month
/
Day
Year
EFFECTIVE DATE
DISABILITY/ESRD
/
Month
/
Day
Year
EFFECTIVE DATE
IF YOUR DEPENDENT CHILD(REN) ARE CURRENTLY COVERED UNDER YOUR NETCARE POLICY, PLEASE COMPLETE THE FOLLOWING:
IF YOU DO NOT HAVE DEPENDENTS OR IF YOUR DEPENDENTS DO NOT HAVE ANY COVERAGE, PLEASE CHECK HERE TO CONTINUE.
DO YOUR DEPENDENT CHILDREN HAVE OTHER HEALTH COVERAGE?
*
YES
NO
DEPENDENT NAME
DOB
-
Month
-
Day
Year
Date
OTHER CARRIER NAME
MEDICARE
PART A
PART B
ID NUMBER
EFFECTIVE DATE
-
Month
-
Day
Year
Date
DEPENDENT NAME
DOB
-
Month
-
Day
Year
Date
OTHER CARRIER NAME
MEDICARE
PART A
PART B
ID NUMBER
EFFECTIVE DATE
-
Month
-
Day
Year
Date
DEPENDENT NAME
DOB
-
Month
-
Day
Year
Date
OTHER CARRIER NAME
MEDICARE
PART A
PART B
ID NUMBER
EFFECTIVE DATE
-
Month
-
Day
Year
Date
EMPLOYEE SIGNATURE
*
DATE
*
/
Month
/
Day
Year
Date
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