Free jdf1810 - Colorado

q District Court
_________________________________________ County, Colorado Court Address: In Re: Petitioner:

Respondent/Co-Petitioner: COURT USE ONLY Attorney or Party Without Attorney (Name and Address): Case Number:

Phone Number: E-mail: FAX Number: Atty. Reg.#: Division Courtroom NOTICE TO INSURANCE PROVIDER OF COURT-ORDERED HEALTH INSURANCE COVERAGE TO: Name of Health Insurance Provider: _______________________________________________________ Address of Health Insurance Provider: _____________________________________________________ Policy Number: ______________________________________________________ Policy Holder/Obligor: _________________________________________________ Address of Obligor: ___________________________________________________

Obligee: ____________________________________________________________________________ Address of Obligee: ___________________________________________________________________ Pursuant to §14-14-112(2.5), C.R.S., the Obligee notifies you that: (a) (b) The Obligor is under a court order to provide health insurance coverage for a child, and The Health Insurance Provider shall notify the Obligee, or the Obligee's representative, of any cancellation of that coverage.

Date:
Obligee/Obligee's Representative

CERTIFICATE OF MAILING I certify that on _____________________________ (date), I placed in the United States mail, postage prepaid, a copy of this Notice addressed to: Name of Health Insurance Provider: _______________________________________________________ Address: ____________________________________________________________________________

Signature
JDF 1810 R7/00 NOTICE TO INSURANCE PROVIDER OF COURT-ORDERED HEALTH INSURANCE COVERAGE PAGE 1 OF 1