Coordination of Benefits (COB) for Retiree Health Coverage
Retiree Information
Name
Retiree ID
Date of Birth
Address
Other Health Coverage
Is there other health coverage?
Yes
No
Other Coverage Provider Name
Policy Number
Medicare Information
Medicare Number
Enrollment Date
Parts Enrolled (A, B, etc.)
Covered Dependents
Name
Relationship
Date of Birth
Other Coverage
Additional Information
Comments or Notes