Form 8126u1 - Multiple Coverage Inquiry
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1
21800 Ninth Avenue
PO Box 91015
Seattle, WA 98111-9115
MULTIPLE COVERAGE INQUIRY
If you and/or your dependents have other insurance, or if coverage existed during the last six months, please complete this form
and return it as soon as possible. This includes coverage by Regence BlueShield, any other BlueCross or BlueShield coverage, any
other insurance company, any retirement plans or Medicare. Note: This form may be used for Uniform Medical Plan, UMP Classic,
or UMP CDHP.
Please sign and complete the form where indicated and submit the completed form to:
Regence BlueShield
Attn: UMP Claims
PO Box 91015 MS BU386
Seattle, Wa 98111-9115
or by fax to: 1-877-357-3418
1. PLEASE ANSWER THIS QUESTION
Do you, or any family member covered by Uniform Medical Plan, have any other health insurance coverage or has any such coverage
existed during the last six months? Include coverage by Regence BlueShield, any other company, any other Blue Shield or Blue Cross
coverage, any retirement plan or Medicare.
YES I f Yes, please fill out the rest of the form if there is other insurance (space has been provided on the back of this form for persons
with more than one other health care plan).
NO
If No, please sign and date the bottom of this form (Section 5), list your telephone number and ID number, and return the form to us
as soon as possible.
2. OTHER INSURANCE INFORMATION (for Medicare, see Section 4)
Name of Insurance Company
Insurance Company Telephone Number
Insurance Company Address (Street or PO Box, City, State, and Zip Code)
Name of Policyholder
Date of Birth
Policyholder Identification Number
Policyholder Social Security Number
Employer
Employer Group ID Number
Date coverage became effective (if not yet, when does it begin):
_______________
If coverage is no longer in effect, date that it ended:_______________
Type of Coverage (Please check all that apply.) Medical
Vision
Dental
Pharmacy
Type of Policy (Please check all that apply.)
Group
Individual Medicaid
Medicare Supplement
Persons Covered by Other Insurance
Name
Date of Birth
Relationship to
Name
Date of Birth
Relationship to
Policyholder
Policyholder
2a. ADDITIONAL OTHER INSURANCE INFORMATION (Complete if applicable. For Medicare, see Section 4)
Name of Insurance Company
Insurance Company Telephone Number
Insurance Company Address (Street or PO Box, City, State, and Zip Code)
Name of Policyholder
Date of Birth
Policyholder Identification Number
Policyholder Social Security Number
Employer
Employer Group ID Number
Date coverage became effective (if not yet, when does it begin):
_______________
If coverage is no longer in effect, date that it ended:_______________
Type of Coverage (Please check all that apply.) Medical
Vision
Dental
Pharmacy
Type of Policy (Please check all that apply.)
Group
Individual Medicaid
Medicare Supplement
Persons Covered by Other Insurance
Name
Date of Birth
Relationship to
Name
Date of Birth
Relationship to
Policyholder
Policyholder
FORM 8126U1 (Rev. 11/12)
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