Court Form 2 Supplement Eff. 7/1/08 IN THE COMMON PLEAS COURT OF HURON COUNTY, OHIO DIVISION OF DOMESTIC RELATIONS : Case No. : CSEA No. Plaintiff/Petitioner (1) : V. Family File No. ________________________ : JUDGE JAMES W. CONWAY Defendant/Petitioner (2)/Respondent : MAGISTRATE BRADLEY E. SALES : HEALTH INSURANCE DISCLOSURE AFFIDAVIT (HIDA) Instructions: This affidavit must be filed according to Local Rules of Court. You are required to disclose all requested information. You may need to consult your employer to complete this form. There is a continuing legal duty to update the information contained in this form. If more space is needed, attach additional page(s). Please type or print legibly. Children Subject to Support Order Husband/Father/Other DOB Name SS# Street Residence Address DOB Name DOB Wife/Mother/Other DOB Street Residence Address SS# SS# Name SS# DOB SS# Name DOB SS# You are to disclose all requested information in the column for you and in the column for the other party. Health Insurance Disclosure Affidavit Page 1 of 5 American LegalNet, Inc. www.FormsWorkflow.com Part I Husband/Father/Other Part II Wife/Mother/Other Name Name Employer Employer Employer Address Employer Address Employer Phone Employer Phone Is Medicaid coverage available? GYes GNo Is Medicaid coverage available? GYes GNo Is Medicare coverage available? GYes GNo Is Medicare coverage available? GYes GNo GYes GNo Is family health insurance available either through the employer or another group or organization? GYes GNo If not, is private insurance available? GYes GNo If not, is private insurance available? GYes GNo Is coverage presently in effect? GYes GNo Is coverage presently in effect? GYes GNo W ho is presently covered? GYes GNo W ho is presently covered? GYes GNo Is family health insurance available either through the employer or another group or organization? Name Relationship Name Relationship Insurer/Plan Name Phone Insurer/Plan Name Phone Address Address Policy/Group # Policy/Group # Other Policy/Group # (if another policy is available) Other Policy/Group # (if another policy is available) Health Insurance Disclosure Affidavit Page 2 of 5 American LegalNet, Inc. www.FormsWorkflow.com You are to disclose all requested information in the column for you and in the column for the other party. Part I Husband/Father/Other Is there a cost for coverage? GYes GNo Part II Wife/Mother/Other Is there a cost for coverage? GYes GNo Special Instruction - The court requires both the family cost and the individual cost information. W hat is the annual cost for family coverage? Special Instruction - The court requires both the family cost and the individual cost information. W hat is the annual cost for family coverage? $ $ W hat is the annual cost for individual coverage? W hat is the annual cost for individual coverage? $ $ Is a health insurance card available? GYes GNo Is a health insurance card available? GYes GNo Are insurance cards required for service? GYes GNo Are insurance cards required for service? GYes GNo Does the plan cover hospitalization? GYes GNo Does the plan cover hospitalization? GYes GNo Is there a deductible for services? GYes GNo Is there a deductible for services? GYes GNo If yes, what is the deductible? $ Check one: Per GVisit Is there a co-payment required? If yes, what is the deductible? GMo. GYr. GYes GNo If yes, what is the co-payment? $ Check one: Per GVisit $ Check one: Per GVisit GMo. Is there a co-payment required? GYr. GYes GNo If yes, what is the co-payment? GMo. GYr. $ Check one: Per GVisit GMo. GYr. GYes GNo Does the plan cover doctor visits? GYes GNo Is there a deductible for services? GYes GNo Is there a deductible for services? GYes GNo If yes, what is the deductible? If yes, what is the deductible? Does the plan cover doctor visits? $ Check one: Per GVisit Is there a co-payment required? GMo. GYr. GYes GNo If yes, what is the co-payment? $ Check one: Per GVisit $ Check one: Per GVisit GMo. Is there a co-payment required? GYr. GYes GNo If yes, what is the co-payment? GMo. GYr. $ Check one: Per GVisit GMo. GYr. Health Insurance Disclosure Affidavit Page 3 of 5 American LegalNet, Inc. www.FormsWorkflow.com You are to disclose all requested information in the column for you and in the column for the other party. Part I Husband/Father/Other Is a prescription card available? GYes GNo Is a co-payment required? GYes GNo Part II Wife/Mother/Other Is a prescription card available? Is a co-payment required? If yes, what is the co-payment? If yes, what is the co-payment? $ $ Per Prescription Per Prescription Is dental coverage available? GYes GNo Is dental coverage available? GYes GNo Insurer/Plan Name Phone Insurer/Plan Name Phone Address Address Policy/Group # Policy/Group # Is there a cost for dental coverage? GYes GNo Is there a cost for dental coverage? GYes GNo Special Instruction - The court requires both the family cost and the individual cost information. What is the annual cost for family dental coverage? Special Instruction - The court requires both the family cost and the individual cost information. What is the annual cost for family dental coverage? $ $ What is the annual cost for individual dental coverage? What is the annual cost for individual dental coverage? $ $ Is a dental insurance card available? GYes GNo Are dental insurance cards required for service? GYes GNo Is a dental insurance card available? GYes GNo Are dental insurance cards required for service? GYes GNo Is vision coverage available? GYes GNo Is vision coverage available? GYes GNo Insurer/Plan Name Phone Insurer/Plan Name Phone Address Address Policy/Group # Policy/Group # Health Insurance Disclosure Affidavit Page 4 of 5 American LegalNet, Inc. www.FormsWorkflow.com You are to disclose all requested information in the column for you and in the column for the other party. Part I Husband/Father/Other Is there a cost for vision coverage? GYes GNo Part II Wife/Mother/Other Is there a cost for vision coverage? GYes GNo Special Instruction - The court requires both the family cost and the individual cost information. What is the annual cost for family vision coverage? Special Instruction - The court requires both the family cost and the individual cost information. What is the annual cost for family vision coverage? $ $ What is the annual cost for individual vision coverage? What is the annual cost for individual vision coverage? $ $ Is a vision insurance card available? GYes GNo Is a vision insurance card available? GYes GNo Are vision insurance cards required for services? GYes GNo Are vision insurance cards required for services? GYes GNo Is COBRA insurance available? GYes GNo (A continuation of present insurance coverage after termination of employment or marriage) Is COBRA insurance available? GYes GNo (A continuation of present insurance coverage after termination of employment or marriage) If yes, at what cost? Check One: If yes, at what cost? GMo. GYr. $ $ Per Check One: GMo. GYr. Per Instructions: In a divorce or post decree action, only the party filling out the Health Insurance Disclosure Affidavit (HIDA) is required to sign the oath. In a dissolution action, both parties must sign the oath. OATH OF AFFIANT(S) - SIGNATURE(S) M UST BE NOTARIZED I hereby swear or affirm that the information set forth in this health insurance disclosure affidavit above is true, complete and accurate. I understand that falsification of this document may result in a contempt of court finding against me which could result in a jail sentence and fine, and that falsification of this document may also subject me to criminal penalties for perjury (O.R.C. 2921.11). AFFIANT - Husband/Father/Other AFFIANT - W ife/Mother/Other Sworn to and subscribed before me this _________ day of _____________________________, 20____. ______________________________________________ Notary Public Health Insurance Disclosure Affidavit Page 5 of 5 American LegalNet, Inc. www.FormsWorkflow.com