Chemung County, NY · Chemung County
Other Insurance Coverage Information
Chemung County employees or subscribers use this required form to report other health insurance coverage for themselves and eligible dependents.
At a glance
- Issued by
- City of Chemung County · Chemung County, Chemung County, New York
- Notarization
- Not required: file this form without a notary.
- Official source
- chemungcountyny.gov
- Blank form
- Download the PDF
- Catalogued
- Machine-readable
- JSON record · about the forms index
What this form is
The form records subscriber and eligible dependent information, including other current or previous medical, prescription, vision, and dental coverage. Complete the applicable coverage sections and sign the form if you or your family members have other coverage or previously had it. The form also asks for coverage dates and details when not all family members are covered by the same plans.
Who needs it
Subscribers completing this required form should provide information about other current or previous health coverage for themselves and their eligible dependents.
How to submit it
Submit it to the Chemung County Insurance Department named on the form; check the county website for current contact details.
About notarization
This form is signed and dated without a notary; it does not identify any notarized attachment or sworn step.
How to submit this form
- 1
Download the Form
Download the Other Insurance Coverage Information form.
- 2
Complete Subscriber Details
Print legibly and fill in subscriber information and eligible dependent details.
- 3
Report Other Coverage
Complete applicable coverage sections for current or previous insurance and identify which family members each plan covers.
- 4
Sign and Submit
Sign and date the form, then submit it to the Chemung County Insurance Department named on the form.
Frequently asked questions
- Who completes the Other Insurance Coverage Information form?
- Subscribers use this required form to report other current or previous health insurance coverage for themselves and eligible dependents.
- What information does the form ask for?
- It asks for subscriber and dependent details, other insurance carriers and coverage types, effective and end dates, and which family members are covered.
- Do I need a notary for the Other Insurance Coverage Information form?
- No. The form calls for the subscriber’s signature and date, but does not identify a notarized attachment or sworn step.
- How do I submit the Other Insurance Coverage Information form?
- Submit it to the Chemung County Insurance Department named on the form. Check the county website for current contact details.