ASR Coordination of Benefits Form ASR COB Form Employee Name First Middle Last Employee Date of Birth Month Day Year Marital Status Single Married/Domestic Partner Divorced Is your spouse/partner employed? Yes No If yes, provide the name, address and phone number of their employer:If your spouse/partner is employed are they eligible for insurance coverage through their employer? Yes No If yes, have they elected coverage through their employer's group health plan? Yes No If yes, please select the coverage(s) they have elected: Medical Dental Vision If coverage(s) has been elected please provide the carrier's name, address and policy/group number:Is health insurance for any of your dependent children mandated by divorce decree or child support order? Yes No If yes, please provide the name(s) of children whose health insurance is mandated and provide a copy of your decree or order to HR to provide to ASR:Who is responsible for providing health insurance for the child(ren) above? First Last Responsible Person's Date of Birth Month Day Year Relationship to the Child(ren) Above Father Mother Who has physical custody of the child(ren) above? Father Mother Are you or any dependents covered by any other group insurance plan, HMO or government plan like Medicare? Yes No If yes, provide name(s) of insured persons:Is the insured an active employee? Yes No Is the insured a COBRA participant? Yes No If yes, please provide a copy of the COBRA election for to HR to provide to ASR.Is the insured a retiree? Yes No Please provide the carrier's name, address, and policy/group number for the other coverage:What is the effective date of the other coverage? Month Day Year What is the termination date of other coverage? Month Day Year CertificationEmployee SignatureDate - must be mm/dd/yyyy format MM slash DD slash YYYY Authorization of Release of Protected Health InformationEmployee SignatureDate - must be mm/dd/yyyy format MM slash DD slash YYYY Spouse/Partner SignatureDate - must be mm/dd/yyyy format MM slash DD slash YYYY Dependent over 18 years old SignatureDate - must be mm/dd/yyyy format MM slash DD slash YYYY Dependent over 18 years old SignatureDate - must be mm/dd/yyyy format MM slash DD slash YYYY Δ
