Laserfiche WebLink
ATTACHMENT I <br /> Page 2 of 2 <br /> • Current Employment Status <br /> - Plan is primary because policyholder is in current employment status. <br /> - Plan is primary for another reason(e.g.,policyholder is an early retiree but <br /> retains primary coverage through the employer because policyholder or <br /> covered dependent has ESRD and is under age 65). <br /> • Coverage Effective Date <br /> • Coverage Termination Date <br /> • Group Plan Number <br /> • Benefits Provided <br /> - Hospital benefits only <br /> - Medical benefits only <br /> - All other types of coverage other than hospital only or medical only <br /> • Coverage <br /> - Self <br /> - Family <br /> - Family, but not spouse <br /> INFORMATION ON PROCESSOR <br /> • Name and address where claim should be sent <br /> INFORMATION ON EMPLOYER <br /> a Name and address of employer that pays the bill for coverage by Plan. <br />