District Court Denver Juvenile Court _________________________________County, Colorado Court Address: In re: The Marriage of: The Civil Union of: Parental Responsibilities concerning: ______________________________________________________ Petitioner: and Co-Petitioner/Respondent: Attorney or Party Without Attorney (Name and Address): COURT USE ONLY Case Number: Phone Number: E-mail: Division Courtroom FAX Number: Atty. Reg. #: NOTICE TO INSURANCE PROVIDER OF COURT-ORDERED HEALTH/DENTAL INSURANCE COVERAGE TO: Name of Health Insurance Provider: _______________________________________________________ Address of Health Insurance Provider: _____________________________________________________ Policy Number: ______________________________________________________ Policy Holder/Obligor: _________________________________________________ Address of Obligor: ___________________________________________________ Obligee: ____________________________________________________________________________ Address of Obligee: ___________________________________________________________________ Pursuant to §14-14-112(2.5), C.R.S., the Obligee notifies you that: (a) (b) The Obligor is under a court order to provide health insurance coverage for a child, and The Health Insurance Provider shall notify the Obligee, or the Obligee's representative, of any cancellation of that coverage. Obligee/Obligee's Representative Date: CERTIFICATE OF MAILING I certify that on _____________________________ (date), I placed in the United States mail, postage prepaid, a copy of this Notice addressed to: Name of Health Insurance Provider: _______________________________________________________ Address: ____________________________________________________________________________ Signature JDF 1810 R7/13 NOTICE TO INSURANCE PROVIDER OF COURT-ORDERED HEALTH INSURANCE COVERAGE © 2013 Colorado Judicial Department for use in the Courts of Colorado American LegalNet, Inc. www.FormsWorkFlow.com