. 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 Date: Obligor Name: Obligor SSN: Case #: Cause #: Bar Code Area W/NCP SSN GREG ABBOTT FS: Attorney General 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: Enrollment Status: Child’s Name: DOB SSN: Enrollment Date: / / / / / / / / / / / / / / / / Mark the item(s) below (with and “X”) to indicate the type of coverage provided: Medical Dental Vision Prescription Drug Mental Health Mark whether claims are sent to the insurance company or directly to you: Other (specify): Insurance Co. Name of Insurance Carrier: Employer Telephone Number: Group Number: Address: - Policy Number: City: State: ZIP Code: - 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? Yes No Employer Contact Info Last Name / Date form completed Telephone Number February 2007 First Name / Position/Title Email Address Form 3F003 American LegalNet, Inc. www.FormsWorkflow.com