Health Insurance Agreement


Health Insurance Agreement

Please fill in the fields below, then click on the "Print Form" button.  Once printed, complete the insurance section on the form manually.   Both parties of the case must sign this form.

 
 

Please verify intended SECONDARY health insurance information for children on this case.

FRIEND OF THE COURT
Renae Topolewski
ASSISTANT FRIEND OF THE COURT
Caryn VanderHeuvel
ST. CLAIR COUNTY FRIEND OF THE COURT
31st Judicial Circuit
201 McMorran Blvd., Room 1600
Port Huron, Michigan 48060
Phone (810) 985-2285
www.stclaircounty.org/Uploads/FoC
 
Agreement to Provide Primary Health Insurance for Children
 
Support Order No: {supportOrderNumber}
 
Plaintiff Signature:
 
Date:
 
 
  
 
Defendant Signature:
 
{defendantSignature}
Date:
 
 
  
 
The parties named above are in agreement that   {inAgreementThat}   shall provide the Primary Health insurance for the children, namely:   {children} .
Parties have agreed that an Order for Primary Insurance be entered for   {partiesOrderPrimary} .

The insurance currently provided is listed below. The insurance intended to be secondary insurance is listed on a
separate page.
 
PRIMARY
 
Medical Insurance:
 
 
Claim Address:
 
 
City, State, Zip:
 
 
Phone No.:
 
 
Date Effective:
Policy No.:
 
 
Group No.:
 
 
Contract No.:
 
 
Medical Insurance:
 
 
Claim Address:
 
 
City, State, Zip:
 
 
Phone No.:
 
 
Date Effective:
Policy No.:
 
 
Group No.:
 
 
Contract No.:
 
 
Medical Insurance:
 
 
Claim Address:
 
 
City, State, Zip:
 
 
Phone No.:
 
 
Date Effective:
Policy No.:
 
 
Group No.:
 
 
Contract No.:
 
 
Medical Insurance:
 
 
Claim Address:
 
 
City, State, Zip:
 
 
Phone No.:
 
 
Date Effective:
Policy No.:
 
 
Group No.:
 
 
Contract No.:
 
 
 
FRIEND OF THE COURT
Renae Topolewski
ASSISTANT FRIEND OF THE COURT
Caryn VanderHeuvel
ST. CLAIR COUNTY FRIEND OF THE COURT
31st Judicial Circuit
201 McMorran Blvd., Room 1600
Port Huron, Michigan 48060
Phone (810) 985-2285
www.stclaircounty.org/Uploads/FoC
 
HEALTH INSURANCE INFORMATION
 
Please verify intended SECONDARY health insurance information for children on this case.
 
     ☐    Court Docket No.:
 
{courtDocketNo}
     ☐    Client Name:
 
{clientName}
     ☐    Name of Children Insured:
 
{insureChildrenName}
     ☐    Policy Holder if other than client:
 
{policyHolder}
     ☐    Name of Employer:
 
{employerName}
 
Medical Insurance:
 
 
Claim Address:
 
 
City, State, Zip:
 
 
Phone No.:
 
 
Date Effective:
Policy No.:
 
 
Group No.:
 
 
Contract No.:
 
 
Medical Insurance:
 
 
Claim Address:
 
 
City, State, Zip:
 
 
Phone No.:
 
 
Date Effective:
Policy No.:
 
 
Group No.:
 
 
Contract No.:
 
 
Medical Insurance:
 
 
Claim Address:
 
 
City, State, Zip:
 
 
Phone No.:
 
 
Date Effective:
Policy No.:
 
 
Group No.:
 
 
Contract No.:
 
 
Medical Insurance:
 
 
Claim Address:
 
 
City, State, Zip:
 
 
Phone No.:
 
 
Date Effective:
Policy No.:
 
 
Group No.:
 
 
Contract No.: