Father shall designate (names and dates of birth of children) as dependents eligible for health insurance coverage in the group health insurance policy offered (i) by Father’s employer or (ii) through another group health care policy, contract, or plan available to Father within thirty days from the date of this order, which (list insurer’s name and policy number). insurer is Father shall supply Mother with (i) information regarding the benefits, limitations, and exclusions of the coverage, (ii) insurance forms necessary to receive reimbursement, payment, or other benefits, and (iii) any necessary insurance cards within thirty days of the issuance of this order. The health plan administrator that provides the health insurance coverage for the children may continue making payment for medical, optical, hospital, dental, or prescription services directly to any health care provider in accordance with the applicable health insurance policy, contract, or plan. shall be responsible for the first $100.00 per year per child of any medical, dental, orthodontia, optical, prescription, psychiatric, psychological, or counseling expenses not paid by insurance. Any additional such expenses, including co-payments and/or deductibles under the health insurance plan for the child(ren), shall be divided between the parties in accordance with each party's income as reflected on the attached child support worksheet as follows: Mother shall pay percent and Father shall pay percent. (Mother/Father) Father shall be liable to Mother for any medical expenses incurred for the child(ren) as a result of Father’s failure to comply with this order. Father and Mother shall comply with ORC §§ 3119.30 through 3119.58. If Father obtains new employment Clermont County CSE shall comply with the requirements of ORC §3119.34, which may result in the issuance of a notice requiring the new employer to take whatever action is necessary to enroll the child(ren) in health care insurance coverage provided by the new employer. Father shall immediately notify Mother and Clermont County CSE if his health insurance coverage through the above-named insurer is changed or terminated for any reason. Form DR-401 American LegalNet, Inc. www.USCourtForms.com