HEALTH INSURANCE INFORMATION FORM  Case No.___________________  NAME OF PERSON PROVIDING INSURANCE: _________________________________________________  PROVIDER OF INSURANCE IS:  ____ Obligor  ____ Obligor’s Spouse  ____ Other  NAME OF INSURANCE COMPANY: ___________________________________________________________  ADDRESS: _______________________________________________________________________________  CITY, STATE, ZIP CODE: ___________________________________________________________________  POLICY EFFECTIVE DATE: ________________  ____ GROUP PLAN  ____ PRIVATE PLAN  POLICY AND/OR GROUP NUMBER: __________________________________________________________  EMPLOYER: ______________________________________________________________________________  EMPLOYER ADDRESS: _____________________________________________________________________  EMPLOYER PHONE: _______________________________________________________________________  * * * * * * * * * * * * * * * * * * * * * * *  NAME OF PERSON PROVIDING INSURANCE: _________________________________________________  PROVIDER OF INSURANCE IS:  ____ Obligee  ____ Obligee’s Spouse  ____ Other  NAME OF INSURANCE COMPANY: ___________________________________________________________  ADDRESS: _______________________________________________________________________________  CITY, STATE, ZIP CODE: ___________________________________________________________________  POLICY EFFECTIVE DATE: ________________  ____ GROUP PLAN  ____ PRIVATE PLAN  POLICY AND/OR GROUP NUMBER: __________________________________________________________  EMPLOYER: ______________________________________________________________________________  EMPLOYER ADDRESS: _____________________________________________________________________  EMPLOYER PHONE: _______________________________________________________________________  THE  FIRST  $100  PER  CHILD  PER  YEAR  OF  MEDICAL  EXPENSES  WHICH  ARE  NOT  COVERED  BY  INSURANCE  SHALL  BE  PAID  BY  ____________________________________.    ANY  ADDITIONAL  EXPENSES  NOT  COVERED  BY  INSURANCE  SHALL  BE  PAID  ___________%  BY  OBLIGOR  AND  ____________% BY OBLIGEE ATTACH COPY OF FRONT AND BACK OF INSURANCE CARD  WCJC Form 2.0  Eff.  04/04/11  American LegalNet, Inc. www.FormsWorkFlow.com