Motion For Health Insurance Coverage {Law 1087}

IN THE CIRCUIT COURT IN THE EIGHTEENTH JUDICIAL CIRCUIT IN AND FOR BREVARD COUNTY, FLORIDA. Case No.: __________________________________, Petitioner and , Respondent Bar Code Label MOTION FOR HEALTH INSURANCE COVERAGE 1. On {date} _________________________, 20___, this Court ordered the child(ren)'s [v one only] [ ] father or [ ] mother to provide health insurance coverage for the following child(ren): Name __________________________ __________________________ __________________________ __________________________ Date of Birth __________ __________ __________ __________ Age ___ ___ ___ ___ Sex ___ ___ ___ ___ Social Security No. _________________ _________________ _________________ _________________ 2. Notice to [v one only] [ ] Petitioner or [ ] Respondent: [v one only] [ ] a. On __________________________, 20___, which is at least 15 days before filing this application, I gave written notice of my intent to seek this order to ___________________ __________________ by [v one only] __certified mail __personal service. [ ] b. The requirement of written notice has been waived by the other party. I ask the Court to order the employer, or other person providing health insurance coverage, to enroll or maintain the child(ren) on any health insurance coverage available to [ ] father [ ] mother. I CERTIFY THAT THE MOTION FOR HEALTH INSURANCE COVERAGE WAS: [v one only] __mailed, __telefaxed and mailed, or __hand delivered to the person(s) listed below on {date}_______________________________, 20___. 3. Law 1087 ­ Rev. 10/2005 American LegalNet, Inc. www.FormsWorkflow.com Motion For Health Insurance Coverage Page 2 Case No:____________________________ Party or their attorney (if represented) Name_____________________________ Address___________________________ _________________________________ City State Zip Other Name________________________________ Address______________________________ _____________________________________ City State Zip DATED:__________________________ _____________________________________ Signature of party signing certificate and pleading Printed name__________________________ Address______________________________ _____________________________________ City State Zip Telephone number______________________ (area code and number) IF A NONLAWYER HELPED YOU FILL OUT THIS FORM TO GIVE TO THE JUDGE TO SIGN, THE NONLAWYER WHO HELPED YOU MUST FILL IN THE BLANKS BELOW: [! fill in all blanks] I, {full legal name and trade name of nonlawyer} ____________________________________, a nonlawyer, located at {street} ______________________________, {city}______________________, {state}______________, {phone}_______________, helped {Petitioner's name} __________________, ____________________________________, who [v one only] _____petitioner or _____ respondent, fill out this form. Law 1087 ­ Rev. 10/2005 American LegalNet, Inc. www.FormsWorkflow.com