Disclosure Of Health Insurance Information

STATE OF MICHIGAN 38TH CIRCUIT MONROE COUNTY DISCLOSURE OF HEALTH INSURANCE INFORMATION Telephone number: (734) 240-7180 CASE NO: Friend of the Court address: 106 E. First Street, Monroe, MI 48161 The information obtained will be treated as confidential and shall not be used or released except for the purposes of administering, enforcing, and complying with state and federal laws governing child support. Check one: EMPLOYEE'S INSURANCE Name of person who carries insurance: MY INS. CURRENT SPOUSE'S INS. Date of birth: OTHER PERSON'S (NOT EX) INS. Social Security Number: Address: Phone No.: Employer Name: Address: Date of Hire Phone No.: Type of insurance available through employer. If new employee, when will coverage become available? ________________ Medical Name of Company at no cost for family insurance at a cost of $___________________ per Address and Phone: week month year Group No. Dental Name of Company at no cost for family insurance at a cost of $___________________ per Address and Phone: week month year Group No. Vision/Optical Name of Company at no cost for family insurance at a cost of $___________________ per Address and Phone: week month year Group No. Prescription Name of Company at no cost for family insurance at a cost of $___________________ per Address and Phone: week month year Group No. Other Name of Company at no cost for family insurance at a cost of $___________________ per Address and Phone: week month year Group No. Which dependents of this case are NOW covered under this insurance? Show effective date of insurance for each. Name DOB Relationship SS# Medical Dental Optical Prescription _________________________ __________ ___________ _____________ _________ _________ _________ _________ Date Date Date Date _________________________ __________ ___________ _____________ _________ _________ _________ _________ _________________________ __________ ___________ _____________ _________ _________ _________ _________ _________________________ __________ ___________ _____________ _________ _________ _________ _________ _________________________ __________ ___________ _____________ _________ _________ _________ _________ Use other side if necessary. Sign and return to the Friend of the Court, Medical Enforcement, 106 E. First St., Monroe, MI 48161. _____________________________________________________________________________________________________ Date Name of Person Preparing Form Phone No. American LegalNet, Inc. www.FormsWorkflow.com