1 2 3 At a term of the Supreme Court of the State of New York, held in and for the County of at , New York on 4 PRESENT: Hon. Justice/Referee --------------------------------------------------------------5 6 Plaintiff, -against7 Defendant. -------------------------------------------------------------NOTICE: YOUR WILLFUL FAILURE TO OBEY THIS ORDER MAY, AFTER A COURT HEARING, RESULT IN YOUR COMMITMENT TO JAIL FOR A TERM NOT TO EXCEED SIX MONTHS, FOR CONTEMPT OF COURT. 8 Pursuant to DRL §240(1). This Qualified Medical Child Support Order (QMCSO) orders and directs that the unemancipated dependents named herein: Name: Date of Birth: Soc. Sec.#: Mailing Address: QUALIFIED MEDICAL CHILD SUPPORT ORDER Index No.: are entitled to be enrolled in and receive the benefits for which the legally responsible relative named herein is eligible, under the group health plan named herein in accordance with Section 609 of the Federal Employee Retirement Income Security Act. 9 The Participant (legally responsible relative) is: Name: Soc. Sec.#: Mailing Address: 10 The Dependents' Custodial Parent or Legal Guardian who is to be provided with any identification cards and benefit claim forms on behalf of dependents: Name: Soc. Sec.#: Mailing Address: (Form UD-8b - Rev. 5/99) 11 The group health plan subject to this order is: 2001 © American LegalNet, Inc. Name: Address: Identification No.: 12 The administrator of said plan is: Name: Address: 13 The type of coverage provided is: 14 ORDERED that coverage shall include all plans covering the health, medical, dental, pharmaceutical and optical needs of the aforementioned Dependents named above for which the Participant is eligible. ORDERED that said coverage shall be effective as of (give date) and shall continue as available until the respective emancipation of the aforementioned dependents. 15 ENTER: 16 DATED: JSC/Referee TO: [Health Insurer] NOTICE: Pursuant to Section 5241(g)(4) of the Civil Practice Laws and Rules, if an employer, organization or group health plan fails to enroll eligible dependents or to deduct from the debtor's income the debtor's share of the premium, such employer, organization or group health plan administrator shall be jointly and severally liable for all medical expenses incurred on behalf of the debtor's dependents named in the execution while such dependents are not so enrolled to the extent of the insurance benefits that should have been provided under such execution. The group health plan is not required to provide any type or form of benefit or option not otherwise provided under the group health plan except to the extent necessary to meet the requirements of a law relating to medical child support described in section one thousand three hundred and ninety six g-1 of title forty-two of the United States Code. (Form UD-8b - Rev. 5/99) 2001 © American LegalNet, Inc.