Free - Ohio

DR617 Eff. 1/06

IN THE COURT OF COMMON PLEAS DIVISION OF DOMESTIC RELATIONS BUTLER COUNTY, OHIO

______________________________
Plaintiff/First Petitioner

JUDGE _______________________ CASE NO.:____________________

-vs______________________________
Defendant/Second Petitioner

HEALTH INSURANCE INFORMATION FORM (PRIMARY INSURANCE)

NAME OF PERSON PROVIDING INSURANCE:___________________________________________ HE/SHE IS: ______ OBLIGOR ______ OBLIGOR'S SPOUSE ______ OBLIGEE ______ OBLIGEE'S SPOUSE ______ OTHER (Explain) ___________________________________________ NAME OF INSURANCE COMPANY: ____________________________________________________ ADDRESS:___________________________________________________________________________ _____________________________________________________________________________________ POLICY EFFECTIVE DATE:__________ GROUP PLAN _________ PRIVATE PLAN __________ POLICY NUMBER:____________________________________________________________________ GROUP NUMBER: ____________________________________________________________________ EMPLOYER:_________________________________________________________________________ EMPLOYER ADDRESS: _______________________________________________________________ _____________________________________________________________________________________ EMPLOYER PHONE: __________________________________________________________________

(SECONDARY INSURANCE) NAME OF PERSON PROVIDING INSURANCE:___________________________________________ HE/SHE IS: ______ OBLIGOR ______ OBLIGEE ______ OBLIGOR'S SPOUSE ______ OBLIGEE'S SPOUSE

______ OTHER (Explain) ___________________________________________ NAME OF INSURANCE COMPANY: ____________________________________________________ ADDRESS:___________________________________________________________________________ _____________________________________________________________________________________ POLICY EFFECTIVE DATE:__________ GROUP PLAN __________ PRIVATE PLAN _________ POLICY NUMBER:____________________________________________________________________ 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