Health Insurance Information Form {WCJC-2}

HEALTH INSURANCE INFORMATION FORM Case No.___________________ NAME OF PERSON PROVIDING INSURANCE: _________________________________________________ PROVIDER OF INSURANCE IS: ____ Obligor ____ Obligor's Spouse ____ Other NAME OF INSURANCE COMPANY: ___________________________________________________________ ADDRESS: _______________________________________________________________________________ CITY, STATE, ZIP CODE: ___________________________________________________________________ POLICY EFFECTIVE DATE: ________________ ____ GROUP PLAN ____ PRIVATE PLAN POLICY AND/OR GROUP NUMBER: __________________________________________________________ EMPLOYER: ______________________________________________________________________________ EMPLOYER ADDRESS: _____________________________________________________________________ EMPLOYER PHONE: _______________________________________________________________________ * * * * * * * * * * * * * * * * * * * * * * * NAME OF PERSON PROVIDING INSURANCE: _________________________________________________ PROVIDER OF INSURANCE IS: ____ Obligee ____ Obligee's Spouse ____ Other NAME OF INSURANCE COMPANY: ___________________________________________________________ ADDRESS: _______________________________________________________________________________ CITY, STATE, ZIP CODE: ___________________________________________________________________ POLICY EFFECTIVE DATE: ________________ ____ GROUP PLAN ____ PRIVATE PLAN POLICY AND/OR GROUP NUMBER: __________________________________________________________ EMPLOYER: ______________________________________________________________________________ EMPLOYER ADDRESS: _____________________________________________________________________ EMPLOYER PHONE: _______________________________________________________________________ THE FIRST $100 PER CHILD PER YEAR OF MEDICAL EXPENSES WHICH ARE NOT COVERED BY INSURANCE SHALL BE PAID BY ____________________________________. ANY ADDITIONAL EXPENSES NOT COVERED BY INSURANCE SHALL BE PAID ___________% BY OBLIGOR AND ____________% BY OBLIGEE ATTACH COPY OF FRONT AND BACK OF INSURANCE CARD WCJC Form 2.0 Eff. 04/04/11 American LegalNet, Inc. www.FormsWorkFlow.com