COB-1

Request for Information on Additional Health Insurance

Thank you for selecting the health insurance offered through your university. HealthSmart Benefit Solutions partners with the university to process claims submitted under this plan. (“Claims” are formal requests for the plan to pay for services you’ve utilized, usually submitted by the providers you see). We strive to provide a smooth and efficient process in the event you do submit a health insurance claim.

To avoid any delays in processing your future claims, HealthSmart needs to know if we should work with any additional health insurance plans that you or your dependent(s) might have.

1. Last name: *

First name *

2. Your SR ID# (the 7 digit number on your Health Insurance ID card) *

Group number *

3. Are you covered by other health insurance? *

Yes

4. Who is covered by your other health insurance?

My spouse/partner

My child/children

Just me

5. Company name of your other health insurance:

6. Primary policyholder name (if other than yourself):

7. Policy #:

Coverage start date:

Policy coverage end date:

8. Insurance company address and phone number:

9. Do you have dependents (for example, spouse or children) who are covered by a different health insurance company not already listed in items 4-8? *

Yes

10. Primary policyholder name:

11. Insurance company name:

12. Policy #:

Coverage start date:

Coverage end date:

13. Insurance company address and phone number: