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Coordination of Benefits Information

Please complete the Coordination of Benefits Information form and send to ASEBP as soon as possible if:

  • you or one of your dependants have extended health, dental, or vision coverage through another insurance provider, or
  • if you need to make any changes to the information ASEBP currently has on file for your family

Examples of changes that ASEBP needs to be made aware of are termination of other coverage, changes in type of coverage, change of insurance provider etc.

Keeping ASEBP up-to-date helps to avoid any potential delays in claim payment and ensures you have accessed all possible sources of payment for your claims.

Note: The ASEBP covered member is the only person who is eligible to sign this form. If you have any questions regarding this form, please contact a Benefit Specialist.

Download the Coordination of Benefits Information form.