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Other Coverage Questionnaire‚Äč

 Other Coverage Questionnaire Form

Other Coverage Questionnaire

All Fields labled with * are required fields





Q1. At the present time are you (the member) or your spouse working?  


 

If not working, please supply the date that you and/or your spouse ceased working (i.e., date of retirement or date of employment termination).


 

 

Q2. Do you or your spouse have group health plan coverage through an employer?  

How many employees work for the employer that offers the group health plan coverage?  

Please supply the name and address of the employer that offers the group health plan coverage.


 

 

 

 

 

Please supply the id, name and address of the group health plan, i.e., the insurance company.


 

 

 

 

 

 

Q3. Do you have group health plan coverage through a family member other than your spouse?  


 

 

 

Please supply the name and address of the family member's employer.


 

 

 

 

 

Please supply the name and address of the group health plan, i.e., the insurance company.


 

 

 

 

 

 

Acknowledgement