Michigan > Local County > Tuscola > Family Division
Health Insurance Information Sheet - Michigan
| Health Insurance Information Sheet Form. This is a Michigan form and can be used in Family Division Tuscola Local County . |
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STATE OF MICHIGAN HEALTH INSURANCE CASE NUMBER TUSCOLA COUNTY INFORMATION SHEET 54TH JUDICIAL CIRCUIT FAMILY DIVISION COMPLETE, SIGN & RETURN TO THE FRIEND OF THE COURT WITHIN 21 DAYS. TUSCOLA CO. COURT HOUSE, 1ST FL., 440 N STATE STREET, CARO, MI 48723 Name: Current Address: Phone Number: Employer Name, Address & Phone Number: YES ______ ______ ______ NO ______ ______ ______ Is health insurance available through your employer? If NO, do you have private health insurance for yourself? Do you maintain health insurance through your spouse's employer? _______________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Please indicate the types of coverage your insurance provides: ______ Medical ______ Dental ______Hospitalization ______ Optical ______ Prescription drugs List names of all children for whom you maintain insurance coverage: _____________________________________________________________________________________ Name Date of Birth _____________________________________________________________________________________ Name Date of Birth _____________________________________________________________________________________ Name Date of Birth (Use back of form if necessary) ATTACHE PHOTOCOPY (Front & Back) OF ANY INSURANCE ID CARD YOU HAVE DATE: ___________________ ____________________________________ YOUR SIGNATURE *MHIS* American LegalNet, Inc. www.FormsWorkFlow.com
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