Member’s Dependent(s) Other Insurance Information:

If you received a request from either CNIC or UMR requesting Dependent(s) Other Insurance Information please complete the form below. By submitting this information a determination can be made as to which coverage is primary for your dependents if they have multiple coverages.

Fields with an orange outline are required. Please fill in the missing information.

Do any dependents have any other coverage for medical, dental, or vision: