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Filling out the Coordination Of Benefits And Affidavit is crucial for managing your medical benefits effectively. This guide provides clear steps to assist you in completing the form accurately and efficiently.

Follow the steps to complete the form correctly.

1. Click ‘Get Form’ button to access the form and open it in the online editor.
2. Begin by indicating your marital status by selecting one of the following options: Single, Married, Separated, or Divorced. If separated or divorced, please provide the relevant dates.
3. Answer whether you are married to another Fund participant or if your dependent child is a participant. If yes, provide the Social Security Number of the other participant.
4. List all enrolled family members who are dependents under your plan by providing their names, relationships, birth dates, and any employer information along with contact numbers.
5. If you or your dependents have other health insurance, provide details such as the dependent's name, the insurance plan's name, group number, policy number, and effective date for coverage. Include what type of coverage is provided (medical, optical, dental, or prescription drug). Indicate 'N/A' if no other coverage exists.
6. If you noted other coverage in the previous step, specify the source of that coverage—such as an employer or spouse's employer.
7. Indicate whether any other coverage was offered to you or your dependents that you declined, including whether any benefits were received for declining the coverage.
8. Sign and date the form where indicated. Provide your Social Security Number, printed name, and contact information for any potential questions.
9. If you need to complete the Affidavit For Other Insurance, provide your name and Social Security Number, affirm the lack of additional health insurance, and sign it. Remember that this affidavit must be notarized before submission.
10. Once all sections are completed, save your changes. You may then download, print, or share the completed form as needed.

Begin filling out your Coordination Of Benefits And Affidavit form online today to ensure efficient management of your medical benefits.