FL-475 - Employer's Health Insurance Return

Summary

Employer's Health Insurance Return

Text

Form ID: FL-475
Title: Employer's Health Insurance Return
Effective Date: 2003-01-01
Mandatory Form: yes
Info Page: https://selfhelp.courts.ca.gov/jcc-form/FL-475
Primary Download URL: https://www.courts.ca.gov/documents/fl475.pdf
Form Detail Page:
Employer's Health Insurance Return
(FL-475)
Gives the judge and the parents information about health insurance coverage available to the employee.
Get form FL-475
Effective: January 1, 2003
PDF Text:
CASE NUMBER:PETITIONER/PLAINTIFF:
RESPONDENT/DEFENDANT:
EMPLOYER'S HEALTH INSURANCE RETURN
1. Name of parent employee:
2. Home address of absent parent employee:
Not known
The employee has the following insurance policies covering health care, vision care, and dental care:4.
Persons insuredType of policyCompany
Date:
(SIGNATURE OF EMPLOYER)(TYPE OR PRINT NAME OF EMPLOYER)
Address:
Telephone No.:
Return this completed return to the following local child support agency within 30 days (name and address of local child 
support agency):
If any insurance coverage lapses, complete the notice below and return a copy to the same local child support 
agency.
NOTICE OF LAPSE IN HEALTH INSURANCE
6. The health insurance listed on the Employer's Health Insurance Return above has
terminated             for (check one):lapsed
all persons insured, for the following reason (specify):a.
for the following reason (specify):the following person (name):b.
Date:
(SIGNATURE OF EMPLOYER)(TYPE OR PRINT NAME OF EMPLOYER)
Address:
Telephone No.:
EMPLOYER'S HEALTH INSURANCE RETURN Family Code, §§ 3771, 3772
www.courtinfo.ca.gov
Form Adopted for Mandatory Use
Judicial Council of California
FL-475 [Rev. January 1, 2003]
Policy No.
The employee has no insurance policies for health care, vision care, or dental care through this employment.3.
FL-475
Page 1 of 1
5.
 Laura Lynn Morgan 31/03 Morgan I Love You

Retrieval chunks

• #1

  Form ID: FL-475 Title: Employer's Health Insurance Return Effective Date: 2003-01-01 Mandatory Form: yes Info Page: https://selfhelp.courts.ca.gov/jcc-form/FL-475 Primary Download URL: https://www.courts.ca.gov/documents/fl475.pdf Form Detail Page: Employer's Health Insurance Return (FL-475) Gives the judge a…