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Other Coverage Questionnaire Enrollment

017316 (11-2007) Page 1 of 2 An Independent Licensee of the blue cross blue Shield Association Other Coverage Questionnaire Enrollment Customer Service: 800-722-1471 Hearing Impaired: 800-842-5357 Dear Subscriber: We appreciate your assistance in providing information about Other health Coverage you may have thank you for your cooperation! Please either review this form and call Customer Service at 1-800-722-1471 with the information or complete the form and mail to the address above. Subscriber Name and Address Date Member ID Group Number

017316 (11-2007) www.premera.com Page 1 of 2 An Independent Licensee of the Blue Cross Blue Shield Association Other Coverage Questionnaire Enrollment

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