Employers Disclosure Of Income And Health Insurance Information Page 3
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3Approved, SCAO
COURT CASE NO.
STATE OF MICHIGAN
EMPLOYER'S DISCLOSURE OF
JUDICIAL CIRCUIT
HEALTH INSURANCE INFORMATION
COUNTY
Friend of the court address
Telephone no.
The information obtained will be treated as confidential and shall not be used or released except for the purposes of administering,
enforcing, and complying with state and federal laws governing child support.
Title
Telephone no.
Name of FOC employee (type or print)
Date
1. Employee name
2. Address
5. Employer federal identification no.
3. Social security number
4. Employer name
6. Employer address
7. IV-D case no.
Complete items 8, 9, and 10 if insurance is available to employee.
8. Medical insurance company name, address, telephone no. Policy number 9. Dental insurance company name, address, telephone no.
Policy number
10. Optical insurance company name, address, telephone no. Policy number 11. What dependent coverage is automatically available?
Medical
Dental
Optical
12. What dependent coverage is available by payment of an additional premium? Specify cost to employee
per individual
per family
Medical
per
Dental
per
Optical
per
13. What dependents of employee are covered?
Effective Date of Coverage
Name
DOB
Relationship
Medical
Dental
Optical
Sign and return to the friend of the court address listed above. Use other side if necessary. See the notice on the other side.
Date
Name and signature of person preparing form
Telephone no.
EMPLOYER'S DISCLOSURE OF HEALTH INSURANCE INFORMATION
FOC 22a (3/08)
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