Employers Declaration Of No Health Insurance Coverage {Law 1025}

IN THE CIRCUIT COURT IN THE EIGHTEENTH JUDICIAL CIRCUIT IN AND FOR BREVARD COUNTY, FLORIDA. Case No.: __________________________________, Petitioner and , Respondent Bar Code Label INSTRUCTIONS TO EMPLOYER OR OTHER PERSON PROVIDING HEALTH INSURANCE 1. 2. If the obligor works for you or health insurance is available through your company, you must give the obligor a copy of this order within 10 days after you receive it. Unless you receive a motion to quash the assignment of insurance benefits, you must take steps to begin or maintain health insurance coverage for the specified child(ren) within the shortest possible time consistent with group plan enrollment rules. The obligor's existing health coverage shall be replaced only if the child(ren) are not provided benefits under the existing coverage where they reside. If the obligor is not enrolled in a plan and there is a choice of several plans, you may enroll the child(ren) in any plan that will reasonably provide benefits of coverage where they live, unless the court has ordered coverage by a specific plan. If no coverage is available, complete the declaration of no health insurance coverage on this page, and mail the declaration by first class mail to the attorney or applicant seeking the coverage within 30 days of your receipt of this order. Keep a copy of the form for your records. If coverage is provided, you must supply evidence of coverage to both parents and any person having custody of the child(ren). Upon request of the parents or person having custody of the child(ren), you must provide all forms, identification cards, and other documentation necessary for submitting claims to the insurance carrier to the extent you provide them to other covered individuals. You must notify the applicant of the effective date of the coverage of the child(ren). You will be liable for any amounts incurred for health care services which would have otherwise been covered under the insurance policy, if you willfully fail to comply with the terms of the order attached. You can also be held in contempt of court. Florida law forbids your firing or taking any disciplinary action against any employee because of the health insurance coverage order. 3. 4. 5. 6. 7. 8. 9. EMPLOYEE INFORMATION The attached order tells your employer or other person providing health insurance coverage for you to enroll or maintain the named child(ren) in a health insurance plan available to you and to deduct the appropriate premium amount or costs, if any, from your wages or other compensation. Law 1025 ­ rev. 10/2005 American LegalNet, Inc. www.FormsWorkflow.com Instructions To Employer Or Other Person Providing Health Insurance Page 2 Case No:_______________________ EMPLOYER'S DECLARATION OF NO HEALTH INSURANCE COVERAGE I, {name} _________________________________ as {position} _______________________________ for {company} _________________________________________________________, located at ___________________________________________________________________________________, whose telephone number is ________________, HEREBY DECLARE THAT NO HEALTH INSURANCE COVERAGE IS AVAILABLE TO OBLIGOR: _________________________________, because {state reasons} ________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ___________________________________________________________________________________. DATED: ___________________________ __________________________________________ Signature of party signing certificate Position ___________________________________ Printed name _______________________________ Address ___________________________________ __________________________________________ City State Zip Telephone _________________________________ (area code and number) Telefax ___________________________________ (area code and number) STATE OF ______________________ COUNTY OF ____________________ Sworn to (or affirmed) and subscribed before me on {date} _______________________, 200__, by {name} _______________________________________. __________________________________________ NOTARY PUBLIC ­ STATE OF FLORIDA __________________________________________ [Print, type, or stamp commissioned name of notary] ___ ___ Personally known Produced identification Type of identification produced ______________________________. Law 1025 ­ rev. 10/2005 American LegalNet, Inc. www.FormsWorkflow.com