A certified copy of this signed order must be served on the employer of the person legally responsible to provide health insurance.

Fields 1-4: The court will fill in these sections.

Field 5: Print the Plaintiff's name.

Field 6: Insert the index number.

Field 7: Print the Defendant's name.

Field 8: Insert the name, date of birth, social security number and mailing address of each unemancipated child of the marriage.

Field 9: Insert the name of the party who must enroll the child(ren) in the health insurance plan available through his or her employment.

Field 10: Insert the name of the party that has custody of or is the legal guardian of the child(ren).

Field 11: Insert the name, address and identification number (if any) of the health plan.

Field 12: Insert the name and address of the administrator of the plan (if any).

Field 13: Describe the type of coverage provided by the plan. Give a detailed description.

Field 14: Leave this section unchanged.

Field 15: Insert the date the parties agree that coverage is to be effective. If not filled in, the court will enter the date the order is signed.

Field 16: The court will fill in this section.