Get Coordination Of Benefits (cob) Form See Reverse Side ... - Rsa-al

The coordination of benefits (COB) form is essential for updating insurance information and ensuring proper coverage. This guide will provide step-by-step instructions on filling out the COB form online, enabling a smooth submission process for users with varying levels of experience.

Follow the steps to successfully complete the COB form online.

1. Click ‘Get Form’ button to obtain the COB form and open it in the editor.
2. In Section A, provide the necessary subscriber information including your social security number or policy ID, full name, telephone number, cell phone number, and email address.
3. Proceed to Section B to disclose any other insurance coverage, excluding Medicare and PEEHIP. Answer 'Yes' or 'No' for you, your spouse, and dependent children regarding other insurance coverage.
4. If you answered 'Yes' to any of the questions in Section B, list each insurance company separately. Include the name of the policyholder, date of birth, contract/policy number, effective date of coverage, termination date (if applicable), and the insurance company phone number.
5. Specify the type of coverage for each insurance company listed in Section B. Check all that apply such as hospital/medical with or without prescription drug coverage, dental, vision, or Tricare.
6. Indicate if you or any of your dependents are covered as dependents on the insurance policy listed.Provide the names and effective dates of coverage for each dependent if applicable.
7. In Section C, read and understand the subscriber certification. You will need to sign and date the form to confirm the accuracy of the provided information.
8. Once you have completed all sections of the form, follow the instructions to submit it online. Ensure to save any changes, download the completed form, or print it for your records.

Complete your COB form online to ensure proper coordination of benefits.