Connection Dental Plus Coordination of Benefits

Family Member First Name Family Member Middle Initial Family Member Last Name Employer Name Employer Address Employer City Employer State
Employer Zip Code

Policyholder First Name Policyholder Middle Initial Policyholder Last Name Relationship to GEHA Member
Is this other coverage Single coverage Family coverage

Is this person Employed Retired

Retirement Date Other Carrier Name Other Carrier Phone Number What is the policy number, contract number or group certificate number of other policy?

Please list family members eligible for other group coverages below
Effective Date * FEHB Plan Name FEHB Code

Coordination of Benefits

Employee or Annuitant Identification Data

Other Group Coverage Information

Signature