COURT OF COMMON PLEAS DIVISION OF DOMESTIC RELATIONS HAMILTON COUNTY, OHIODate:Plaintiff / PetitionerCase No.-vs/and-File No.CSEA No.Defendant / PetitionerJudgeGROUP HEALTH INSURANCE AFFIDAVIT*********************************************************************************************************Plaintiff/Petitioner YesDefendant/Petitioner YesNo YesNo YesAvailable through employment Other group plan INSURERS NAME ADDRESSNo Company Name AddressCity St Zip POLICY NUMBERNo Company Name AddressCity St ZIP POLICY NUMBERPOLICY NUMBERMonthly premium of Individual Plan (employee share) Monthly premium of Family Plan (employee share)$$$$COVERAGES Summarize health care benefits, i.e., major medical only, deductible, co-payments, health maintenance organization, etc. Attach separate sheet where necessary.()Yes() No (Is coverage presently in effect? Who is Covered Is a participant card available? Is prescription card available? Employer's Ins. Coordinator's Name and Telephone Number) No (()Yes() Self() Above named spouse () Above named spouse (() Self) Dependent children of the marriage () Dependent children of the marriage ()Yes() No () No (()Yes)Yes() No Emp. Ins. Phone #()YesThe cost to purchase COBRA coverage will be$$) No Emp. Ins. Phone #Plaintiff/PetitionerDefendant/PetitionerState of Ohio, County of Hamilton: Sworn to before me and subscribed in my presence by Plaintiff/Petitioner this day of , 20.Notary PublicSworn to before me and subscribed in my presence by Defendant/Petitioner this day of , 20.Notary PublicDR 7.16TP (Oct. 1999)2001 © American LegalNet, Inc.
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