COURT OF COMMON PLEAS

DIVISION OF DOMESTIC RELATIONS

Available through employment

Other group plan

INSURERS NAME

ADDRESS

POLICY NUMBER

Monthly premium of Individual Plan (employee share)

Monthly premium of Family Plan (employee share)

HAMILTON COUNTY, OHIO

Plaintiff / Petitioner
-vs/and-
Defendant / Petitioner
Enter:
Date:
Case No.
File No.
CSEA No.
Judge
GROUP HEALTH INSURANCE AFFIDAVIT

*********************************************************************************************************

Plaintiff/Petitioner
Yes	No
Yes	No
Company Name
Address
City St Zip
POLICY NUMBER
$
$
()Yes	() No
() Self () Above named spouse
() Dependent children of the marriage
()Yes	() No
()Yes	() No
Emp. Ins.
Phone #
$
Defendant/Petitioner
Yes	No
Yes	No
Company Name
Address
City St ZIP
POLICY NUMBER
$
$
()Yes	() No
() Self () Above named spouse
() Dependent children of the marriage
()Yes	() No
()Yes	() No
Emp. Ins.
Phone #
$

COVERAGES

Summarize health care benefits, i.e., major medical only, deductible, co-payments, health maintenance organization, etc. Attach separate sheet where necessary.

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

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