COURT OF COMMON PLEAS DIVISION OF DOMESTIC RELATIONS HAMILTON COUNTY, OHIO Enter: Plaintiff / Petitioner Date: Case No. -vs/andFile No. E CSEA No.# Defendant / Petitioner Judge GROUP HEALTH INSURANCE AFFIDAVIT *********************************************************************************************************** Plaintiff/Petitioner Defendant/Petitioner ______Yes _____No Available through employment _____Yes _____No _____ Yes _____No Other group plan _____ Yes _____ No INSURERS NAME ADDRESS POLICY NUMBER $____________ $____________ Monthly premium of Individual Plan (employee share) $____________ Monthly premium of Family Plan (employee share) $____________ COVERAGES Summarize health care benefits, i.e., major medical only, deductible, co-payments, health maintenance organization, etc. Attach separate sheet where necessary. _______ _______ ( )Yes ( ) No ( ) Self ( ) Above named spouse ( ) Dependent children of the marriage ( ) Yes ( ) No ( ) Yes ( ) No Emp. Ins.___________________________ Phone #____________________________ Is coverage presently in effect? Who is Covered Is a participant card available? Is prescription card available? Employer's Ins. Coordinator's Name and Telephone Number ( )Yes ( ) No ( ) Self ( ) Above named spouse ( ) Dependent children of the marriage ( ) Yes ( ) No ( ) Yes ( ) No Emp. Ins.____________________________ Phone #_____________________________ $____________ The cost to purchase COBRA coverage will be $____________ ______________________________________________________ Plaintiff/Petitioner Defendant/Petitioner State of Ohio, County of Hamilton: Sworn to before me and subscribed in my presence by Plaintiff/Petitioner this _______day of __________________________, 20___________. Notary Public Sworn to before me and subscribed in my presence by Defendant/Petitioner this ________day of _______________________, 20___________. Notary Public DR 7.16 (Revised 10/01/1999) American LegalNet, Inc. www.FormsWorkFlow.com