This is a Health Insurance Affidavit to be used when the couple divorcing have minor children born of the marriage. This form is used to provide the Court with all relevant health insurance information of both parties.
Health Insurance Affidavit For Students
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You are required to disclose all requested information. You may need to consult your employer and insurer to complete this form.Members in the CalPERS Health Benefits Program. The creation of the Children's Health Insurance Program (CHIP). These include federal tax, state tax, FICA, wage attachments, health insurance, union dues, etc. And other similar amounts. I understand that failure to complete this form may result in delayed, denied or termination of coverage for the above named dependent. If you have children, they might qualify for coverage under the Children's Health Insurance Program (CHIP) — even if you don't qualify for Medicaid.