FL-470 - Application And Order For Health Insurance Coverage

Summary

Application And Order For Health Insurance Coverage

Text

Form ID: FL-470
Title: Application And Order For Health Insurance Coverage
Effective Date: 2007-01-01
Mandatory Form: yes
Info Page: https://selfhelp.courts.ca.gov/jcc-form/FL-470
Primary Download URL: https://www.courts.ca.gov/documents/fl470.pdf
Form Detail Page:
Application And Order For Health Insurance Coverage
(FL-470)
Ask the judge to make the employer of a parent include the children in their health insurance coverage. It also tells the employer to include the children in the health insurance.
Get form FL-470
Effective: January 1, 2007
PDF Text:
FL-470
FOR COURT USE ONLY
CASE NUMBER:
APPLICATION AND ORDER FOR HEALTH INSURANCE COVERAGE
APPLICATION
1.   On (date):  , this court ordered obligor (name): 
2.   a. On (date):
by first-class mail by personal service.
OR
Obligor has waived the requirement of written notice.b.
3.   I ask the court to order the employer or other person providing health insurance coverage to enroll or maintain the children in any 
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Date:
(SIGNATURE OF APPLICANT)(TYPE OR PRINT NAME)
ORDER FOR HEALTH INSURANCE COVERAGE (ASSIGNMENT)
To employer or other person providing health insurance coverage for obligor (name): 
YOU ARE ORDERED TO
1. Begin or maintain health insurance coverage of:
You may deduct any premium or costs from the wages or earnings of obligor.
2.   If the obligor works for you or if you provide health insurance coverage to obligor, give him or her a copy of this order within 10 days
after you receive it.
3.   If no health insurance coverage is available to the obligor, complete and sign the Declaration of No Health Insurance Coverage on
the reverse and mail this form within 20 days to the attorney or person requesting the assignment.
Date:
(JUDICIAL OFFICER) Page 1 of 2
Form Adopted for Mandatory Use 
Judicial Council of California     
FL-470 [Rev. January 1, 2007]
APPLICATION AND ORDER FOR 
HEALTH INSURANCE COVERAGE
Family Code, §§ 3760–3772 
, which is at least 15 days before the filing of this application,
to provide health insurance coverage for the children named in the order below.
Social security number (if known): 
I gave written notice to obligor of my intent to seek this order below 
Name of child Date of birth Social security No.
health insurance coverage available to the obligor.
www.courtinfo.ca.gov
MARRIAGE OF
PETITIONER:
RESPONDENT:
ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address):
TELEPHONE NO.:
ATTORNEY FOR (Name):
SUPERIOR COURT OF CALIFORNIA, COUNTY OF
STREET ADDRESS:
MAILING ADDRESS:
CITY AND ZIP CODE:
BRANCH NAME:
E-MAIL ADDRESS (Optional):
FAX NO. (Optional):

MARRIAGE OF (Last name, first name of each party): CASE NUMBER:
DECLARATION OF NO HEALTH INSURANCE COVERAGE
No health insurance coverage is available to the obligor (name): 
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Date:
(TYPE OR PRINT NAME AND TITLE) (SIGNATURE OF EMPLOYER OR PERSON PROVIDING HEALTH INSURANCE)
MAIL A COPY OF THIS DECLARATION WITHIN 20 DAYS TO THE ATTORNEY OR PERSON SEEKING THIS ENROLLMENT 
(SEE INSTRUCTION NO. 5, BELOW).
INSTRUCTIONS 
FOR EMPLOYER OR OTHER PERSON PROVIDING HEALTH INSURANCE
These instructions apply only to an Order for Health Insurance Coverage issued by a court.
1.   If the obligor works for you or is covered by health insurance provided by you, you must give him or her a copy of this order within  
2.   Unless you receive a motion to quash the assignment, you must take steps to begin or maintain coverage of the specified children
within 30 days after you deliver a copy of this order to th e obligor. The coverage should begin at the earliest possible time 
consistent with group plan enrollment rules.
3.   The obligor’s existing health coverage will be replaced only if the children are not provided benefits under the existing coverage 
4.   If the obligor is not enrolled in a plan and there is a choice of several plans, you may enroll the children in any plan that will 
5.   If no coverage is available, complete the Declaration of No Health Insurance Coverage at the top of this page and mail the
declaration by first-class mail to the attorney or person seeking the assignment within 20 days of your receipt of this order. Keep a 
copy of the form for your records.
6.   If coverage is provided, you must supply evidence of coverage to both parents and to any person having custody of the child.
7.   Upon request of the parents or person having custody of the child, you must provide all forms and other documentation necessary 
8.   You must notify the applicant of the effective date of the coverage of the children.
9.   You will be liable for any amounts incurred for health care services that otherwise would have been covered under the insurance
policy if you willfully fail to comply with this order. You can also be held in contempt of court. California law forbids your firing or 
taking any disciplinary action against any employee because of this order.
EMPLOYEE INFORMATION
1.   This order tells your employer or other person providing health insurance coverage to you to enroll or maintain the named children
in a health insurance plan available to you and to deduct the appropriate premium or costs, if any, from your wages or other 
compensation.
2.   You have 15 days after you receive a copy of this order to object to the order. Family Code section 3765 tells you how.
Page 2 of 2APPLICATION AND ORDER FOR 
HEALTH INSURANCE COVERAGE
FL-470 [Rev. January 1, 2007]
because (state reasons):
3.   Family Code section 3770 tells you how and when to petition the court to end this assignment.
10 days after you receive it.
where they reside.
reasonably provide benefits or coverage where they live, unless the court has ordered coverage by a specific plan.
for submitting claims to the insurance carrier to the extent you provide them to other covered individuals.
FL-470

Retrieval chunks

• #1

  Form ID: FL-470 Title: Application And Order For Health Insurance Coverage Effective Date: 2007-01-01 Mandatory Form: yes Info Page: https://selfhelp.courts.ca.gov/jcc-form/FL-470 Primary Download URL: https://www.courts.ca.gov/documents/fl470.pdf Form Detail Page: Application And Order For Health Insurance Cov…

• #2

  ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address): TELEPHONE NO.: ATTORNEY FOR (Name): SUPERIOR COURT OF CALIFORNIA, COUNTY OF STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME: E-MAIL ADDRESS (Optional): FAX NO. (Optional): MARRIAGE OF (Last name, first name of each part…

• #3

  policy if you willfully fail to comply with this order. You can also be held in contempt of court. California law forbids your firing or taking any disciplinary action against any employee because of this order. EMPLOYEE INFORMATION 1. This order tells your employer or other person providing health insurance cove…