Select your TPA Group Name:
Subscriber's Name:
Subscriber's Social Security Number:
Other than this Medical Plan, does your Spouse or dependent Children have coverage through another Group Medical Plan, either through another Employer or through a government agency?

Yes

No
 

If you answered "No", please scroll down past the questions that are highlighted in blue.

If you answered "Yes", please complete the following questions highlighted in blue:
 
Select the type of other coverage:

Employer Group Medical Plan

Employer Retiree Group Medical Plan

Medicare

Medicaid

Other
If you answered "other," please explain:  
If the other Medical Plan is Medicare, select the type of coverage included:

Part A

Part B
 
Who is covered under this Medical Plan?  Select all that apply.

You

Natural Parent

Spouse

Child(ren)

Step-child(ren)

Other
If you answered "other," please explain  
 
List the names of individuals covered under the plan:
 
What is the name of the primary member or subscriber under this Medical Plan?
What is the Social Security number of the primary member or subscriber?
What is the date of birth of the primary member or subscriber?
What is the name of this Medical Plan?
Who is the insurance carrier for this Medical Plan?
If the Medical Plan is through an Employer, what is the name of the Employer?
What is the telephone number of the Employer?
What is the effective date of this coverage?
   
Your email address:
Your Home Telephone Number:
Your Work Telephone Number:
 

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