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COB Form

Other Health Coverage - Coordination of Benefits Information

Employee Name

DOB

Member ID

As the third-party administrator for Prime Healthcare Services, Keenan &
Associates is responsible to determine the proper order of benefit payments if
other health insurance coverage exists. Please complete, sign and return this
document using one of the following.

Are you and your dependents currently enrolled in any other Health
Insurance coverage?

Note: In order to establish which Health Insurance coverage is primary,
please provide either a court order or divorce decree regarding health
insurance, if applicable.

Sign

Signature

Enter your Full Name

Date of Submission