Insurance COB Audit Questionnaire Form
Please complete this questionnaire to assist with the insurance coordination of benefits audit. All fields are required unless otherwise noted. Do not enter sensitive personal or financial information.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Employer Name
Primary Insurance Carrier
*
Primary Policy Number
*
Primary Policy Effective Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Do you have any additional insurance coverage?
*
Yes
No
If yes, please provide the secondary insurance carrier and policy number.
Please describe any recent changes to your insurance coverage (e.g., plan changes, new dependents, loss of coverage).
Submit
Should be Empty: