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 OFFICE OF THE ATTORNEY GENERAL STATE OF TEXAS CHILD SUPPORT DIVISION Employer Address: _________________ _________________ _________________ _________________ Date: ______________________ Obligee/Obligor Name: _______________________ Obligee/Obligor SSN: _______________________ Case #: ______________________ Cause #: ______________________ GREG ABBOTT Attorney General Area W/CP SSN FS: OTHER SOURCE HEALTH INSURANCE INFORMATION Please provide this agency with the information requested below regarding your employee (obligor) within 20 business days after the date of the notice, or sooner, if reasonable. PLEASE RETURN THIS FORM TO THE ADDRESS LISTED ABOVE ***Please enclose copies of: Health insurance policy; Schedule of benefits; Insurance membership cards; Claim forms*** Child Name DOB SSN Enrollment Date Complete the following for all children that have health insurance from another source If insurance details are unknown, provide the employee's address and phone number: Mark the item(s) below (with a "X") to indicate the type of coverage provided: Medical Dental Vision Prescription Drug Mental Health Telephone Number: Other (specify): Name of Insurance Carrier: Group Number: Address: State: ZIP Code: Policy Number: City: - - 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 Last Name First Name Contact Info Date form completed Position/Title / Telephone Number / Email Address - - FOR OAG VENDOR ONLY Date valid insurance confirmed May 2010 American LegalNet, Inc. www.FormsWorkFlow.com
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