ASR Coordination of Benefits Form

ASR COB Form

  • Employee Name
  • Marital Status
  • Is your spouse/partner employed?
  • If your spouse/partner is employed are they eligible for insurance coverage through their employer?
  • If yes, have they elected coverage through their employer's group health plan?
  • If yes, please select the coverage(s) they have elected:
  • Is health insurance for any of your dependent children mandated by divorce decree or child support order?
  • Who is responsible for providing health insurance for the child(ren) above?
  • Relationship to the Child(ren) Above
  • Who has physical custody of the child(ren) above?
  • Are you or any dependents covered by any other group insurance plan, HMO or government plan like Medicare?
  • Is the insured an active employee?
  • Is the insured a COBRA participant?
  • Is the insured a retiree?
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY