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Notice To Insurance Provider Of Court Ordered Health Insurance Coverage JDF 1810 - Colorado
|Notice To Insurance Provider Of Court Ordered Health Insurance Coverage Form. This is a Colorado form and can be used in Domestic Relations Statewide .||
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q District Court _________________________________________ County, Colorado Court Address: In Re: Petitioner: Respondent/Co-Petitioner: COURT USE ONLY Attorney or Party Without Attorney (Name and Address): Case Number: Phone Number: E-mail: FAX Number: Atty. Reg.#: Division Courtroom NOTICE TO INSURANCE PROVIDER OF COURT-ORDERED HEALTH INSURANCE COVERAGE TO: Name of Health Insurance Provider: _______________________________________________________ Address of Health Insurance Provider: _____________________________________________________ Policy Number: ______________________________________________________ Policy Holder/Obligor: _________________________________________________ Address of Obligor: ___________________________________________________ Obligee: ____________________________________________________________________________ Address of Obligee: ___________________________________________________________________ Pursuant to §14-14-112(2.5), C.R.S., the Obligee notifies you that: (a) (b) The Obligor is under a court order to provide health insurance coverage for a child, and The Health Insurance Provider shall notify the Obligee, or the Obligee's representative, of any cancellation of that coverage. Date: Obligee/Obligee's Representative CERTIFICATE OF MAILING I certify that on _____________________________ (date), I placed in the United States mail, postage prepaid, a copy of this Notice addressed to: Name of Health Insurance Provider: _______________________________________________________ Address: ____________________________________________________________________________ Signature JDF 1810 R7/00 NOTICE TO INSURANCE PROVIDER OF COURT-ORDERED HEALTH INSURANCE COVERAGE PAGE 1 OF 1 2002 © American LegalNet, Inc.