Coordination Of Benefits Form For Young Adult Coverage (Page 2 of 2) in pdf

2. Employer Health Plan

Can your young adult dependent receive health insurance through his/her employer?

| — | Yes

| — | No

If they can, do they currently receive it? | — | Yes

| — | No

Please provide the following information:

• 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: | — | — | — | – | — | — | — | – | — | — | — | — |

3. Spousal Health Plan

Does your young adult dependent receive health insurance through his/her spouse’s employer?

| — | Yes | — | No

If yes, please provide the following information:

• Spouse’s Full Name: | — | — | — | — | — | — | — | — | — | — | — | — | — | — | — | — | — | — | — | — |

Spouse’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: | — | — | — | – | — | — | — | – | — | — | — | — |

This coordination of benefits form is for Fund use only, and it will not be released to any third party except where necessary for the administration and operation of the Fund, or where otherwise required

by law. The foregoing statements are to the best of my knowledge true and complete. I authorize any hospital, physician or other healthcare provider to release to the Fund and its agents any records of

information, without restriction, concerning me or any member of my family receiving benefits from the Fund. Unless I revoke it in writing, this authorization will be effective as long as I am a participant

in the Fund. A photocopy of this authorization shall be as valid as the original. I understand that under the terms of the plan (SPD), the Fund has a right to be reimbursed for any money it pays on my behalf

for expenses caused by a third party. If the Fund pays any such claims, it will have a lien on payments I receive from, or on behalf of, the third party, and I agree to pay back the Fund for any payments it

has made. This agreement will be effective for all benefits incurred while I am a participant in the Fund, even if I receive payments from, or on behalf of, a third party when I am no longer a participant.

I certify that the foregoing is true and correct.

Member’s Signature X

Date:

Failure to respond will create a gap in coverage for the young adult dependent.