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Employers Health Insurance Return FL-475 - California
|Employers Health Insurance Return Form. This is a California form and can be used in Family Law - Enforcement Judicial Council .||
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FL-475 PETITIONER/PLAINTIFF: RESPONDENT/DEFENDANT: CASE NUMBER: EMPLOYER'S HEALTH INSURANCE RETURN 1. Name of parent employee: 2. Home address of absent parent employee: Not known 3. The employee has no insurance policies for health care, vision care, or dental care through this employment. 4. The employee has the following insurance policies covering health care, vision care, and dental care: Company Type of policy Policy No. Persons insured Date: (TYPE OR PRINT NAME OF EMPLOYER) (SIGNATURE OF EMPLOYER) Address: Telephone No.: 5. Return this completed return to the following local child support agency within 30 days (name and address of local child support agency): If any insurance coverage lapses, complete the notice below and return a copy to the same local child support agency. NOTICE OF LAPSE IN HEALTH INSURANCE 6. The health insurance listed on the Employer's Health Insurance Return above has lapsed terminated for (check one): a. all persons insured, for the following reason (specify): b. the following person (name): for the following reason (specify): Date: (TYPE OR PRINT NAME OF EMPLOYER) (SIGNATURE OF EMPLOYER) Address: Telephone No.: Page 1 of 1 Form Adopted for Mandatory Use Judicial Council of California FL-475 [Rev. January 1, 2003] EMPLOYER'S HEALTH INSURANCE RETURN Family Code, §§ 3771, 3772 www.courtinfo.ca.gov 2002 © American LegalNet, Inc.