Spousal Coordination of Benefits Form

PLEASE READ CAREFULLY - IMPORTANT INFORMATION

The Spousal Coordination of Benefits(SCOB) Policy is used to determine your spouse’s eligibility to receive primary coverage in the State of Delaware Group Health Insurance Plan. Please note, the SCOB Policy does not apply to dental or vision benefits.

THIS FORM DOES NOT ENROLL OR TERMINATE YOUR SPOUSE'S COVERAGE IN YOUR HEALTH PLAN.

To enroll or terminate your spouse in your health plan, you must contact your human resources representative.

FAILURE TO COMPLETE THE SCOB FORM OR PROVIDE DOCUMENTATION WHEN REQUIRED WILL RESULT IN A REDUCTION OF YOUR SPOUSE’S COVERAGE.

If you cover a spouse under your health plan, you are required to complete the online SCOB Form when the following events occur:

  • Enroll your spouse,
  • Anytime your spouse loses or gains employee coverage, and
  • Every year during the Annual Benefits Open Enrollment.

You, your spouse, or your spouse’s employer may be required to provide additional information.

You are responsible for understanding the requirements of the SCOB Policy described here, for providing verification as noted, and for the accuracy of the information in this form. If any information entered on this form is found to be false or incorrect and medical claims are paid based on the false or incorrect information, you will be required to reimburse the State.

As you complete this form, only the sections that require a response will be opened for data entry. Any grayed-out sections do not require a response.