Coordination Of Benefits Form For Young Adult Coverage
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21199SEIU Benefit Funds
330 West 42nd Street, New York, NY 10036-6977 •
Tel (646) 473-9200 • Outside NYC Area Codes: (800) 575-7771
Coordination of Benefits Form for Young Adult Coverage
Instructions: Complete a separate Coordination of Benefits Form for Young Adult Coverage for each dependent child from age 19 up to age 26
for whom you are requesting Benefit Fund coverage. Please print clearly in blue or black ink and place one character per box.
1199SEIU Benefit and Pension Funds
Member Eligibility Department
PO Box 1035
New York, NY 10108-1035
Member’s Information
Member’s Full Name: ________________________________________________________________________________________
Member ID: ____________________________________________ Benefit Fund (NBF or GNY): _____________________________
Address: _________________________________________________________________________________________________
City: _________________________________________________ State: __________ Zip Code: ___________________________
Home #: | — | — | — | – | — | — | — | – | — | — | — | — | Cell #: | — | — | — | – | — | — | — | – | — | — | — | — |
Email Address: | — | — | — | — | — | — | — | — | — | — | — | — | — | — | — | — | — | — | — | — | — | — | —
Young Adult’s Information
Dependent’s Full Name: ______________________________________________________________________________________
Social Security #: XXX-XX- _______________________________ Sex: | — | M
| — | F
Address (if different from member):
| — | — | — | — | — | — | — | — | — | — | — | — | — | — | — | — | — | — | — | |
City: | — | — | — | — | — | — | — | — | — | — | — | — | | State: | — | — |
Zip Code:
| — | — | — | — | — |
Home #: | — | — | — | – | — | — | — | – | — | — | — | — | Cell #: | — | — | — | – | — | — | — | – | — | — | — | — |
Email Address: | — | — | — | — | — | — | — | — | — | — | — | — | — | — | — | — | — | — | — | — | — | — | — |
Please indicate in the following sections if your young adult can receive health insurance through another source.
Fill out all that apply:
1. Other Parent’s Health Plan
Can your young adult dependent receive health insurance through his/her other parent’s employer?
| — | Yes
| — | No
If yes, please provide the following information:
• Parent’s Full Name: | — | — | — | — | — | — | — | — | — | — | — | — | — | — | — | — | — | — | — | — |
Parent’s Date of Birth: | — | — | / | — | — | / | — | — | — | — |
Month
Day
Year
• Employer’s Full Name: | — | — | — | — | — | — | — | — | — | — | — | — | — | — | — | — | — | — | — | — | — |
| — | — | — | — | — | — | — | — | — | — | — | — | — | — | — | — | — | — | — | — | — |
• Employer’s Address:
City: | — | — | — | — | — | — | — | — | — | — | — | — | — | State: | — | — |
Zip Code: | — | — | — | — | — |
Please Indicate the Type of Coverage (Check all that apply):
| — | Medical
| — | Hospital
| — | Prescription
| — | Dental
| — | Vision
Effective Date of Coverage: | — | — | / | — | — | / | — | — | — | — |
Month
Day
Year
• Name of Insurance Plan: | — | — | — | — | — | — | — | — | — | — | — | — | — | — | — | — | — | — | — | — | — |
Policy/Group #: | — | — | — | — | — | — | — | — | — | — |
Insurance Plan Telephone: | — | — | — | – | — | — | — | – | — | — | — | — |
AFELI01 • 10/11
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