3601 W. Olive Ave., Burbank, CA 91505 • Mailing Address: P.O. Box 7830, Burbank, CA 91510-7830
P (800) 777-4013 • F (818)
Coordination of Benefits (COB) Questionnaire Form
In order for us to process claims for you and your dependents, you must complete this Coordination of Benefits questionnaire and
return it to us. If we don’t receive the completed, signed form, future claims may be denied without further notice. In that event,
you or your provider will have 180 days to either provide the required information or appeal the denial.
Participant name:
Health care ID (HCID):
Aside from your SAG-AFTRA Health Plan and/or Medicare, are you, your spouse or children covered by
another health insurance plan? __Yes __No
If yes, who is the insured? Insured’s health care ID number:
Name of other plan: Other plan’s phone:
Effective date of coverage: Termination date:
Coverage type: __Group (through employer) __Individual/private (obtained on own)
Coverage status: __Active __Retiree __COBRA Level of coverage: __Family __Individual
List family members covered:
Do you or any other family member qualify for coverage with any other entertainment industry health plan,
regardless of whether or not you paid the premium for that coverage? __Yes __No
If yes, name of person who qualified for coverage:
Name of other industry plan: Qualifying person’s ID number:
Effective date of coverage: Termination date:
Coverage status: Active Retiree COBRA Level of coverage: Family Individual
Participant signature
Please disregard this form if you have
already returned a completed form to the Plan.
To complete this form online simply log in to your Benefits Manager at
. Click on Menu,
Go Paperless, then Forms and Letters. If you have additional questions, please call us at (800) 777-4013.
Rev 03/15/19
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