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Get MI WF 10339 2010-2024

NO Please skip the rest of the questions YES Please complete entire form sign at the bottom and return OTHER HEALTH COVERAGE INFORMATION Please provide the following information about the policy holder of the other health coverage. Attach additional pages if needed. Name of policy holder of other coverage Relationship to you Social security number Employer Birth date Insurance company name Enrollee ID / policy number Group number Type of coverage Single Family Is this a retiree contract Is this a COBRA contract Is policy holder laid-off Yes City State Effective date No Type of plan Who is covered by this other plan Include yourself if applicable. Name first and last Cancellation date if applicable Hospital check all that apply Dental Drugs Medical ZIP code SPECIAL SITUATIONS Fill out this section only if any of your children have health care coverage in addition to the above because of divorce separation etc. Is there a court order that determines responsibility for health care coverage or custody Name of person responsible for child s health care coverage Yes - attach a copy of the sections that apply to health care responsibility and/or custody arrangements Which children are covered by this insurance Child s name first and last Who has custody Subscriber s signature Return completed forms to Date COB Membership 0526 Blue Cross Blue Shield of Michigan 600 E. Lafayette Blvd. COORDINATION OF BENEFITS QUESTIONNAIRE LOCAL For your convenience you can update your coordination of benefits information online at bcbsm*com/cob. If neither you nor your covered dependents have any additional group health coverage simply call our automated response number at 866-611-7474. SECTION 1 YOUR BCBSM INFORMATION BCBSM enrollee name as found on your ID card In addition to this BCBSM contract are you or any of your covered dependents also covered by another group health care plan other than Medicare If you have additional BCBSM contracts please include this as other coverage. NO Please skip the rest of the questions YES Please complete entire form sign at the bottom and return OTHER HEALTH COVERAGE INFORMATION Please provide the following information about the policy holder of the other health coverage. Attach additional pages if needed* Name of policy holder of other coverage Relationship to you Social security number Employer Birth date Insurance company name Enrollee ID / policy number Group number Type of coverage Single Family Is this a retiree contract Is this a COBRA contract Is policy holder laid-off Yes City State Effective date No Type of plan Who is covered by this other plan Include yourself if applicable. Name first and last Cancellation date if applicable Hospital check all that apply Dental Drugs Medical ZIP code SPECIAL SITUATIONS Fill out this section only if any of your children have health care coverage in addition to the above because of divorce separation etc* Is there a court order that determines responsibility for health care coverage or custody Name of person responsible for child s health care coverage Yes - attach a copy of the sections that apply to health care responsibility and/or custody arrangements Which children are covered by this insurance Child s name first and last Who has custody Subscriber s signature Return completed forms to Date COB Membership 0526 Blue Cross Blue Shield of Michigan 600 E* Lafayette Blvd. .

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