Health Insurance Disclosure

Tuscola County Friend of the Court: 440 N. State Street, Caro, MI 48723 PH: 989-673-4848 FAX: 989-673-4898 Health Insurance Disclosure Form Tuscola County FOC Your Name: _________________________________________________________ Docket Number: _____________________________________________________ Current Address: _____________________________________________________ Phone Number: ______________________________________________________ Employer Name: _____________________________________________________ Employer Address: ___________________________________________________ Employer Phone: _____________________________________________________ Do you or your current spouse carry insurance on your child(ren) (This includes private, employer or state aid insurance.) Yes____ or No___? IF YOU ANSWERED YES, PLEASE ANSWER THE FOLLOWING QUESTIONS: Who carries the insurance (check the appropriate box): You _____ or Your Spouse_____ Name of Insurance Company: _______________________________________________ Address of Insurance Company: _____________________________________________ Group Number: __________________________________________________________ Policy Number: __________________________________________________________ Effective Date: ___________________________________________________________ Types of coverage your insurance provides (check all that apply): Medical_____ Dental_____ Vision_____ Prescription_____ Hospitalization____ 8. List the names of all children that are covered by this policy: ___________________________________________________________________ Name Date of Birth ___________________________________________________________________ Name Date of Birth ___________________________________________________________________ Name Date of Birth ___________________________________________________________________ Name Date of Birth ___________________________________________________________________ Name Date of Birth ___________________________________________________________________ Name Date of Birth 1. 2. 3. 4. 5. 6. 7. PLEASE ATTACH PHOTOCOPY (Front & Back) OF YOUR INSURANCE CARD Date: ________________ Signature: ____________________________________ American LegalNet, Inc. www.FormsWorkFlow.com