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Click ‘Get Form’ to open the 1199 coordination of benefits form in the editor.
Begin by filling in the Member’s Information section. Clearly print your full name, Member ID, and Benefit Fund details. Ensure your address, phone numbers, and email are accurate.
Next, provide the Young Adult’s Information. Enter your dependent's full name, Social Security number (last four digits), sex, and contact details if different from yours.
Indicate if your young adult can receive health insurance through another source. Fill out all applicable sections regarding other parent’s health plan, employer health plan, or spousal health plan.
For each section filled out, check the types of coverage available and provide effective dates along with insurance plan details.
Finally, review all information for accuracy before signing at the bottom of the form. Your signature certifies that all information is true and complete.
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