IN THE COURT OF COMMON PLEAS DIVISION OF DOMESTIC RELATIONS CUYAHOGA COUNTY, OHIO ____________________________ Plaintiff/Petitioner/Defendant-1 : Case No.: D-______________________ : SETS No.: _______________________ -vs: _____________________________ Defendant/Respondent/Defendant-2 : HEALTH INSURANCE INVESTIGATIVE FORM 1. Are you eligible for family health coverage through any group health plan maintained by your employer or another group or organization? ___ yes ___ no If yes, provide the following information about the employer or other group or organization: a. Name: __________________________________________________________ b. Address: __________________________________________________________ c. Telephone No.: __________________________________________________________ d. Name of Benefits Coordinator: _____________________________________________ 2. If post decree matter, is the health coverage through your present spouse? ___ yes ___ no If yes, your spouse’s name _______________________________________________________ 3. Are you currently enrolled in a plan for ____ single coverage ____ family coverage ____ neither. a. If you are enrolled in a plan, the date of enrollment: _____________________________ b. If you are not enrolled in a plan, the date you are eligible, if any: ___________________ 4. If enrolled in a plan or will/could be enrolled, please provide the following information: a. Insurance Company’s Name: _______________________________________________ b. Address: _______________________________________________________________ c. Telephone Number: ______________________________________________________ d. Claim’s Dept. address, if different: __________________________________________ e. Name of the Plan:_________________ Group No.___________ Policy No. _________ f. Cost per month for: Single Coverage (employee share) ____________ Family Coverage (employee share) ____________ 5. Type of Coverage: _____ PPO _____ HMO _____ Traditional (unrestricted providers) 6. The types of benefits available through the insurance: ____ medical ____ hospital ____ prescription drug ____ mental health ____ substance abuse 7. Are ____ participant cards and/or ____ prescription cards available? If yes, please attach copy. 8 Supplemental Coverage: Do you have ____ dental and/or ____ vision coverage available? If yes, please provide the following information: a. Insurance Company’s Name(s): ____________________________________________________ b. Claims Address(s): ______________________________________________________________ c. Telephone Number(s): ___________________________________________________________ d. Cost per month for: Single Coverage (employee share) _______ dental _______ vision Family Coverage (employee share) _______ dental _______ vision 9. Child(ren) who are currently covered as dependents of participant: Name DOB SSN Effective Date of Enrollment/Coverage _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _______________________________________ Signature of Parent _______________________________________ Street _______________________________________ City State Zip Code DR0706106 Health Insurance Investigative Form (____)___________________________ Home Telephone Number ________________________________ Driver’s License No. State American LegalNet, Inc. www.FormsWorkflow.com