Request For Group Coverage/enrollment Form Page 5
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65. Other Coverage/ Authorization To Release Information
As a new participant of the Christian Brothers Employee Benefit Trust, it is necessary for you to
complete the information requested below. Failure to do so will result in a delay in processing your
initial request for benefits.
Employee
Location #:
Name:
Employee SSN:
Employee
Address:
Other Coverage Information
Please x one of the following categories and provide the requested information if it applies.
Single
Widowed
Divorced
Religious
Married(Spouse’s Name):
Birth Date:
Social Security #:
If yes, please provide name address and telephone number.
Do you have any
________________________________________________________________________
________________________________________________________________________
additional
Yes
No
________________________________________________________________________
Employers?
________________________________________________________________________
Do you have any
If yes, please provide name address and telephone number.
________________________________________________________________________
other coverage
________________________________________________________________________
(including AARP)?
________________________________________________________________________
Yes
No
________________________________________________________________________
Do your dependent
If yes, please provide name address and telephone number.
________________________________________________________________________
children (if any) have
________________________________________________________________________
any other coverage
________________________________________________________________________
Yes
No
(including AARP)?
________________________________________________________________________
If yes, please provide name address and telephone number.
________________________________________________________________________
Is your spouse
________________________________________________________________________
Yes
No
employed?
________________________________________________________________________
________________________________________________________________________
If yes, please provide name address and telephone number.
Spouse’s other
________________________________________________________________________
________________________________________________________________________
coverage (including
Yes
No
________________________________________________________________________
AARP)?
________________________________________________________________________
ANY CHANGE IN OTHER COVERAGE INFORMATION MUST BE REPORTED TO OUR OFFICE.
I HEREBY CERTIFY THAT ALL INFORMATION, STATEMENTS
Signed (Employee)
Date
AND ANSWERS MADE ON THIS FORM ARE COMPLETE AND
TRUE TO THE BEST OF MY KNOWLEDGE.
AUTHORIZATION TO RELEASE INFORMATION
Signed (Employee)
Date
: I authorize any
physician, hospital, or other health care provider to release to Christian Brothers
Employee Benefit Trust, or its representative, any information regarding my medical
history, symptoms, treatment, examination results, or diagnosis. A photocopy of this
authorization shall be considered as effective and valid as the original. This
authorization shall be considered valid for one year from the date signed. I
understand I have a right to received a copy of this authorization.
Rev.08/24/2010
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