Employer Health Insurance Enrollment Form
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Employer Health Insurance Enrollment Form. This is a Texas form and can be use in Attorney General Statewide.
Tags: Employer Health Insurance Enrollment Form, 3F003, Texas Statewide, Attorney General
Office of the Attorney General
MEDICAL SUPPORT UNIT
P.O. BOX 1328
AUSTIN, TEXAS 78767-1328
Toll-Free (800) 522-2421
FAX (512) 279-1723
Bar Code Area W/NCP SSN
EMPLOYER HEALTH INSURANCE ENROLLMENT
Please provide this agency with the information requested below regarding your employee (obligor).
PLEASE RETURN THIS FORM TO THE ADDRESS LISTED ABOVE
Texas Family Code, Section 154.187 requires that you reply no later than 30 days
after the date you receive the court order for health insurance enrollment.
***Please enclose copies of: Health insurance policy; Schedule of benefits; Insurance membership cards; Claim forms***
In the “Enrollment Status” boxes below, write in the appropriate number for each child:
-Write the number “1” in the enrollment status box if the child is enrolled in a health insurance plan;
-Write “2” in the enrollment status box if the child cannot be enrolled in a health insurance plan for the following reason:
Mark the item(s) below (with and “X”) to indicate the type of coverage provided:
Mark whether claims are sent to the insurance company or directly to you:
Name of Insurance Carrier:
Please PRINT legibly within the boxes, do not cross the lines, use black ink!
Do you currently withhold child support related wages from this employee?
Date form completed
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