ORDER TO MAINTAIN HEALTH INSURANCE FOR MINOR CHILD(REN) JD-FM-125 Rev. 7-16 C.G.S. 46b-84(e) STATE OF CONNECTICUT SUPERIOR COURT www.jud.ct.gov Court Use Only INSURE To be prepared by counsel or parties and submitted to the court for verification and certification. Distribution: ORIGINAL: Court File COPY: Custodial Parent or Custodian Docket number Name of defendant *INSURE* Name and address of court Name of plaintiff Type of case Date of order Dissolution Case status Annulment Final Judgment Legal Separation PostJudgment Support Action Custody Action Custodial parent or custodian (If joint custody, parent who maintains primary place of residence for child(ren) Pendente Lite 1. The above-named plaintiff defendant is ordered to maintain the following health insurance coverage as available in the manner prescribed below for the benefit of the below-named child(ren): Type of Coverage Available Through Medical Other (Specify) His/her employment Name Dental Hospitalization His/her union Date of birth Other available group plan Name Privately Date of birth Children To Be Covered The above-mentioned order of health insurance is subject to the following conditions, if any: 2. The above-mentioned health insurance coverage is to be effective on (date): 3. Said plaintiff defendant is ordered to provide certification or verification of such insurance to the: Department of Social Services Custodial Parent Custodian Support Enforcement Office on or before (date): Family Services Office 4. It is further ordered that: A. the signature of the custodial parent or custodian of the insured minor child(ren) shall constitute a valid authorization to the insurer for purposes of processing an insurance reimbursement payment to the provider of the medical services or to the custodial parent or custodian; B. neither parent shall prevent or interfere with the timely processing of any insurance reimbursement claim; and C. if the parent receiving an insurance reimbursement payment is not the parent who is paying the bill for the services of the medical provider, the parent receiving such insurance reimbursement payment shall promptly pay to the parent or custodian paying such bill any insurance reimbursement for such services. By the Court (Print or type name of Judge/Family Support Magistrate) Signed (Judge, Family Support Magistrate, Clerk, Assistant Clerk) Date signed Certification I hereby certify that the above order is a true copy of the order requiring maintenance of health insurance for the abovenamed child(ren). In testimony whereof, I have hereunto set my hand and affixed the seal of said court at the above location on: Date Signed (Clerk, Assistant Clerk) SEE IMPORTANT NOTICE TO CUSTODIAL PARENT OR CUSTODIAN ON PAGE 2 American LegalNet, Inc. www.FormsWorkFlow.com Notice To The Custodial Parent Or Guardian Pursuant to Section 46b-84(e) of the Connecticut General Statutes, the custodial parent or custodian is responsible for providing the insurer with a certified copy of the order requiring maintenance of health insurance for a minor child as well as any subsequent modification of the order. Health Insurance Provider Information (Do not complete until after the court has certified the order on the reverse side.) The information provided below is not being certified by the court and is provided for informational purposes only. Health Insurance Provider Group number Membership number JD-FM-125 (page 2) Rev. 7-16 Page 2 of 2 ADA NOTICE The Judicial Branch of the State of Connecticut complies with the Americans with Disabilities Act (ADA). If you need a reasonable accommodation in accordance with the ADA, contact a court clerk or an ADA contact person listed at www.jud.ct.gov/ADA. American LegalNet, Inc. www.FormsWorkFlow.com