________________________________________________________________________________________________________________________________________
NAME OF INSURANCE PLAN EFFECTIVE DATE OF COVERAGE (MM/DD/YYYY)
________________________________________________________________________________________________________________________________________
POLICY/GROUP # INSURANCE PLAN PHONE NUMBER
2. EMPLOYER HEALTH PLAN
Does your young adult dependent receive health insurance through his or her employer? No Yes
If “Yes,” please provide the following information:
________________________________________________________________________________________________________________________________________
NAME OF EMPLOYER
________________________________________________________________________________________________________________________________________
EMPLOYER’S ADDRESS CITY STATE ZIP CODE
Please indicate the type of coverage (check all that apply): Medical Hospital Prescription Dental Vision
________________________________________________________________________________________________________________________________________
NAME OF INSURANCE PLAN EFFECTIVE DATE OF COVERAGE (MM/DD/YYYY)
________________________________________________________________________________________________________________________________________
POLICY/GROUP # INSURANCE PLAN PHONE NUMBER
3. SPOUSAL HEALTH PLAN
Does your young adult dependent receive health insurance through his or her spouse’s employer? No Yes
If “Yes,” please provide the following information:
________________________________________________________________________________________________________________________________________
SPOUSE’S FULL NAME (FIRST AND LAST) SPOUSE’S DATE OF BIRTH (MM/DD/YYYY)
________________________________________________________________________________________________________________________________________
NAME OF EMPLOYER
________________________________________________________________________________________________________________________________________
EMPLOYER’S ADDRESS CITY STATE ZIP CODE
Please indicate the type of coverage (check all that apply): Medical Hospital Prescription Dental Vision
________________________________________________________________________________________________________________________________________
NAME OF INSURANCE PLAN EFFECTIVE DATE OF COVERAGE (MM/DD/YYYY)
________________________________________________________________________________________________________________________________________
POLICY/GROUP # INSURANCE PLAN PHONE NUMBER
READ BELOW. PRINT OUT THE COMPLETED FORM, THEN SIGN AND DATE IT.
THE FORM CANNOT BE PROCESSED WITHOUT THE MEMBER’S AND THE YOUNG ADULT’S SIGNATURE.
FAILURE TO RESPOND WILL CREATE A GAP IN COVERAGE FOR YOUR YOUNG ADULT DEPENDENT.
This coordination of benefits form is for the 1199SEIU Benefit Funds’ use only, and will not be released to any third party except where necessary for the administration and operation of the Benefit Funds, 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 Benefit Funds
and its agents any records of information, without restriction, concerning me or any member of my family receiving benefits from the Benefit Funds. Unless I revoke it in writing, this authorization will be effective
as long as I am a participant in the Benefit Funds. I understand that under the terms of the Plan (Section I.G of the Summary Plan Description), the Benefit Funds has the right to be reimbursed for any money it
pays on my behalf for expenses caused by a third party. If the Benefit Funds pay 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 Benefit
Funds for any payments it has made. This agreement will be effective for all benefits incurred while I am a participant in the Benefit Funds, even if I receive payments from, or on behalf of, a third party when
I am no longer a participant. If I provided my email address on this form, I consent to receiving Benefit Funds information by email, and I understand that communications over the Internet may not be secure.
X _________________________________________________________________________________________________________________________________________
MEMBER’S SIGNATURE (REQUIRED) DATE (MM/DD/YYYY) (REQUIRED)
X _________________________________________________________________________________________________________________________________________
YOUNG ADULT’S SIGNATURE (REQUIRED) DATE (MM/DD/YYYY) (REQUIRED)
AFELI01 • 08/20 • COB FOR YOUNG ADULT COVERAGE
