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Coordination of Benefits Form

If you have more than one insurance plan, co-ordination of benefits (COB) is a way to decide which insurance company is responsible for payment.

The COB form requires the signature of the policy holder.

Your insurance company may require you to complete a COB form to determine if they are responsible for payment. Contact your insurance plan for specific information regarding their policies and procedures.

Click on the links below to download the appropriate forms:

*The PDF files above is in Adobe Acrobat format and requires the Acrobat Reader to view it. If you do not have the Acrobat Reader, you can download it for FREE at http://www.adobe.com/products/acrobat/readstep.html.


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Edward Hospital & Health Services
801 S. Washington, Naperville, IL 60540 • (630) 527-3000

Naperville • Plainfield • Bolingbrook • Oswego • Woodridge
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