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Click ‘Get Form’ to open the Coordination of Benefits Questionnaire in the editor.
Begin by checking the reason for submission at the top of the form. Select from options such as 'Annual COB update' or 'New enrollee'.
Fill in your Group Policy Number and Group or Employer Name in the designated fields.
Enter your Member ID, Member/Employee Name, Address, and Phone Number accurately.
Indicate whether you or any covered dependents have other health coverage. If 'YES', complete all sections; if 'NO', sign at the bottom and return.
In Section 1, provide details about other health coverage, including policy holder information and type of coverage. Attach additional pages if necessary.
If applicable, complete Section 2 regarding special situations for dependent children, including custody details.
Finally, fill out Section 3 if you or your spouse has Medicare coverage, providing effective dates for Hospital Parts A and B.

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