Form 8126u1 - Multiple Coverage Inquiry Page 2
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22b. 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If coverage is no longer in effect, date that it ended:_______________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
3. If your dependent child(ren) are covered under another plan and the natural parents are divorced or separated, Washington State
regulations require that we ask the following:
Name of Parent With Custody (Please indicate if parents have dual custody.)
If divorced, did the court establish financial responsibility for
the children’s health care?
YES
NO
If Yes, specify the name of the person with financial responsibility
Date of Divorce
INCLUDE A COPY OF THE CHILD
MAINTENANCE AGREEMENT FROM
THE DIVORCE DECREE.
Address of Person With Financial Responsibility (Street or PO Box, City, State and Zip Code)
4. Medicare: If you or any family member are covered by Medicare, please provide the following information.
Member’s Name:
Medicare HIC Number:
Part A Effective Date:
Part B Effective Date:
If coverage began before age 65, please state the reason:
Member’s Name:
Medicare HIC Number:
Part A Effective Date:
Part B Effective Date:
If coverage began before age 65, please state the reason:
Member’s Name:
Medicare HIC Number:
Part A Effective Date:
Part B Effective Date:
If coverage began before age 65, please state the reason:
5. SUBSCRIBER’S SIGNATURE
Subscriber’s UMP ID Number
Date
Work Telephone
Home Telephone
Subscriber’s Name (please print)
Subscriber’s Signature
FORM 8126U2 (Rev. 11/12)
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