IN THE SUPERIOR COURT FOR THE STATE OF ALASKA AT ) ) ) ) ) ) ) ) ) ) To: Employer Address CASE NO. NOTICE TO EMPLOYER RE: CHILDREN'S MEDICAL INSURANCE The court has ordered your employee, , to purchase health insurance for the children listed on page one of the attached child support order. The medical support order is on page four of the order. Alaska Statute 25.27.063 requires the court to send a copy of the medical support order to you if your employee is eligible for family health care coverage through his/her employment. That statute also requires the following: 1. You must allow the employee named in the order to enroll the child(ren) under the family coverage without regard to restrictions relating to enrollment periods if the child(ren) are otherwise eligible and not already enrolled. If the employee fails to apply for enrollment of a child named in the attached order, you must enroll the child under the employee's family coverage upon application by the child's other parent or custodian, the Child Support Enforcement Services (CSSD), or the Department of Health and Social Services. You may not disenroll or eliminate coverage of a child while the employee is still employed by you unless you eliminate family health coverage for all your employees or you receive written evidence that a. the employee is no longer required by court order or administrative order to provide the child's insurance coverage; or b. the child is or will be enrolled in comparable health coverage through another insurer that will take effect not later than the effective date of the disenrollment or elimination of coverage. You must withhold from the employee's compensation the employee's share, if any, of premiums for health coverage to the extent permitted under 15 U.S.C. 1673(b) (Consumer Credit Protection Act) and pay the withheld amount to the appropriate insurer. If federal regulations allow you to withhold less than the employee's share of the insurance premium, you may withhold the lesser amount and pay it to the appropriate insurer. 2. 3. 4. Date Distribution: 1. Employer 2. Court File Judge/Clerk/Deputy Clerk 3. Employee 4. Other Parent 5. CSSD AS 25.27.063 American LegalNet, Inc. www.FormsWorkFlow.com DR-330 (3/12)(cs) NOTICE TO EMPLOYER Re: CHILDREN'S MEDICAL INSURANCE