t are not covered yet. write "Pending" under Policy or ID #. Policy or ID # Name of person(s) covered by Ibis insurance. Primary Insurance Company Major Medical Insurance Company Other Insurance (Union. Dental. Vision. etc.) Medicare Medicaid Workers' Compensation Auto Insurance Other insurance Rev September 2015 Page

t are not covered yet. write "Pending" under Policy or ID P. Policy or ID a Name of person(s) covered by this insurance: Pnmary Insurance Company Major Medical Insurance Company Other Insurance (Union, Dental, Vision, etc.) Medicare Medicaid Workers' Compensation Auto Insurance Other insurance Rev. September 2015 Page