Employer Health Insurance Enrollment {3F003}

Office of the Attorney General MEDICAL SUPPORT UNIT P.O. BOX 1328 AUSTIN, TEXAS 78767-1328 Toll-Free (800) 522-2421 FAX (855)-329-6676 <F004> <F005> <F006> <F007> <F008> <F009> <F010> Date: <F002> Obligor Name: <F024> <F025> <F026> Obligor SSN: <F022> Case #: <F003> Cause #: <F040> FS: <F019> ***Once received, send copies of: Health Insurance policies, Schedules of benefits, Insurance membership cards and Claim forms to the MEDICAL SUPPORT UNIT, P.O. Box 1328, Austin, TX 78767-1328.*** In the "Enroll" column, CIRCLE "Y" if the child is enrolled in a health insurance plan; "N" if the child cannot be enrolled in a health insurance plan and provide the reason: _______________________________________________________ Enroll (Y/N) Child's Name DOB SSN Enrollment Date Y/N ____________________________________ _____________ ______________ ___/____/______ Y/N ____________________________________ _____________ ______________ ___/____/______ Y/N ____________________________________ _____________ ______________ ___/____/______ Y/N ____________________________________ _____________ ______________ ___/____/______ Y/N ____________________________________ _____________ ______________ ___/____/______ Y/N ____________________________________ _____________ ______________ ___/____/______ Y/N ____________________________________ _____________ ______________ ___/____/______ Y/N ____________________________________ _____________ ______________ ___/____/______ Y/N ____________________________________ _____________ _____________ __/____/_____ Y/N ____________________________________ _____________ ______________ ___/____/______ Select one of the following: ___ a. The child(ren) is/are currently enrolled in the plan as a dependent of the participant. ___ b. There is only one type of coverage provided under the plan. The child(ren) is/are included as dependents of the participant under the plan. ___ c. The participant is enrolled in an option that is providing dependent coverage and the child(ren) will be enrolled in the same option. ___ d. The participant is enrolled in an option that permits dependent coverage that has not been elected; dependent coverage will be provided. Employer Contact Information: ______________________________________ Title:_____________________________ Telephone Number:_________________ Email: ____________________________________ Date: ________________ The participant (employee) and dependents (alternate recipients) are to be enrolled in the following family coverage with the following carrier(s) information. (Identify the types of coverage for each insurance carrier.) Name Of Insurance Carrier: ________________________________ Telephone Number: ________________________ Group Number: _____________________________________ Policy Number: _________________________________ Address: __________________________________________________________________________________________ Mark the coverages provided by the policy with an `X': ____Medical ____ Dental ____ Vision ____Prescription Drug ____Mental Health ____ Other:____________________ Name Of Insurance Carrier: ________________________________ Telephone Number: ________________________ Group Number: _____________________________________ Policy Number: _________________________________ Address: __________________________________________________________________________________________ Mark the coverages provided by the policy with an `X': ____Medical ____ Dental ____ Vision ____Prescription Drug ____Mental Health ____ Other:____________________ November 2014 American LegalNet, Inc. www.FormsWorkFlow.com Please provide this agency with the information requested below regarding your employee and return the form to the address above. Texas Family Code, Section 154.187 requires that you reply within 40 business days after the date of the notice, or sooner if reasonable. EMPLOYER HEALTH INSURANCE ENROLLMENT 3F003 Name Of Insurance Carrier: ________________________________ Telephone Number: ________________________ Group Number: _____________________________________ Policy Number: _________________________________ Address: __________________________________________________________________________________________ Mark the coverages provided by the policy with an `X': ____Medical ____ Dental ____ Vision ____Prescription Drug ____Mental Health ____ Other:____________________ Name Of Insurance Carrier: ________________________________ Telephone Number: ________________________ Group Number: _____________________________________ Policy Number: _________________________________ Address: __________________________________________________________________________________________ Mark the coverages provided by the policy with an `X': ____Medical ____ Dental ____ Vision ____Prescription Drug ____Mental Health ____ Other:____________________ Name Of Insurance Carrier: ________________________________ Telephone Number: ________________________ Group Number: _____________________________________ Policy Number: _________________________________ Address: __________________________________________________________________________________________ Mark the coverages provided by the policy with an `X': ____Medical ____ Dental ____ Vision ____Prescription Drug ____Mental Health ____ Other:____________________ Name Of Insurance Carrier: ________________________________ Telephone Number: ________________________ Group Number: _____________________________________ Policy Number: _________________________________ Address: __________________________________________________________________________________________ Mark the coverages provided by the policy with an `X': ____Medical ____ Dental ____ Vision ____Prescription Drug ____Mental Health ____ Other:____________________ American LegalNet, Inc. www.FormsWorkFlow.com