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Application and Order for Health Insurance Coverage

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APPLICATION AND ORDER FOR HEALTH INSURANCE COVERAGE

ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, state bar number, and address):

TELEPHONE NO.:

FAX NO.:

ATTORNEY FOR (Name):

FL470

FOR COURT USE ONLY

CASE NUMBER

SUPERIOR COURT OF CALIFORNIA, COUNTY OF

STREET ADDRESS:

MAILING ADDRESS:

CITY AND ZIP CODE:

BRANCH NAME:

MARRIAGE OF

PETITIONER:

RESPONDENT:

APPLICATION AND ORDER FOR HEALTH INSURANCE COVERAGE

CASE NUMBER

APPLICATION

1. On (date): , this court ordered obligor (name):

to provide health insurance coverage for the children named in the order below.

2. a. On (date): , which is at least 15 days before filing this application,

I gave written notice to obligor of my intent to seek this order

by first-class mail

by personal service.

OR

b. Obligor has waived the requirement of written notice.

3. I ask the court to order the employer or other person providing health insurance coverage to enroll or maintain the children in any health insurance coverage available to the obligor.

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)

(SIGNATURE OF APPLICANT)

ORDER FOR HEALTH INSURANCE COVERAGE (ASSIGNMENT)

To employer or other person providing health insurance coverage for obligor (name):

Social Security Number (if known):

YOU ARE ORDERED TO

1. Begin or maintain health insurance coverage of:

Name of child

Date of birth

Social Security No.

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:

(JUDGE OF THE SUPERIOR COURT)

For Judicial Council of California

FL-470 [Rev. January 1, 2007]

APPLICATION AND ORDER FOR

HEALTH INSURANCE COVERAGE

page 1 of 2

Family Code, §§ 3760-3772

MARRIAGE OF (last name, first name of parties):

CASE NUMBER

DECLARATION OF NO HEALTH INSURANCE COVERAGE

No health insurance coverage is available to the obligor (name):

because (state reasons):

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 10 days after you receive it.

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 receive this order. The coverage should begin at the earliest possible time consistent with group plan enrollment rules.

3. The obligor's existing health coverage shall be replaced only if the children are not provided benefits under the existing coverage where they reside.

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 reasonably provide benefits or coverage where they live, unless the court has ordered coverage by a specific plan.

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 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 for submitting claims to the insurance carrier to the extent you provide them to other covered individuals.

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 would otherwise 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 to contest this order. Family Code section 3765 tells you how.

3. Family Code section 3770 tells you how and when to petition the court to end this assignment.

FL-470 [Rev. January 1, 2007]

APPLICATION AND ORDER FOR

HEALTH INSURANCE COVERAGE

Page 2 of 2

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What the Application and Order for Health Insurance Coverage Is

The Application and Order for Health Insurance Coverage is a formal document used to request enrollment in a health insurance policy or to change coverage level. It typically collects applicant identification, plan selection, dependent information, medical history disclosures, and payment authorization. Completed applications create the contractual basis for coverage once accepted by the insurer and may trigger underwriting, eligibility verification, and premium billing processes.

Why an Accurate Application Matters

Completing this form accurately speeds enrollment, reduces underwriting delays, and helps protect coverage eligibility. Clear, verifiable answers reduce the risk of coverage gaps, claim denials, or future rescission and support compliance with consumer-protection and privacy laws such as ESIGN and HIPAA.

Why an Accurate Application Matters

Who Completes and Relies on This Form

Each user group has slightly different data needs and consent obligations; employers and brokers must follow additional disclosure and verification procedures when acting as intermediaries.

  • Consumers and applicants submitting enrollment or changes directly to an insurer or exchange.
  • Licensed agents and brokers submitting group or individual enrollments on behalf of clients.
  • Employers and benefits administrators enrolling employees in employer-sponsored plans.

Representative Signers and Submitters

Insurance Agent

A licensed agent completes fields for client identity, plan selection, and agent disclosure information, and must obtain applicant consent for electronic delivery and data sharing under ESIGN (15 U.S.C. ch. 96) and applicable state rules.

Benefits Manager

An employer benefits manager may complete group enrollment data, verify employee eligibility, collect dependent documentation, and retain records consistent with HIPAA and company retention policies.

Core Components You’ll Find on the Form

A professional application groups related data into discrete sections so insurers can verify eligibility and evaluate risk quickly.

Applicant Details

Full legal name, date of birth, contact information, and Social Security number or TIN for identity verification and tax reporting purposes.

Coverage Selection

Selected plan type, coverage tier, and optional riders or add-ons. Precisely identify plan codes or product names to avoid processing errors.

Dependent Information

Names, DOBs, and relationship of dependents plus documentation requirements for spouse or child coverage eligibility.

Medical History

Disclosure questions about preexisting conditions and prior treatments used in underwriting; answer fully to avoid later disputes.

Payment Authorization

Premium billing method, bank or card details if applicable, and explicit consent for recurring payments where required.

Declarations & Signatures

Attestations, consent statements, and signature block for applicant (or authorized representative) with dated signature to create the enrollment record.

Step-by-Step: How to Complete the Application

Follow these steps in order to prepare a complete, verifiable application suitable for electronic submission and secure archiving.

  • 01
    Collect ID: Gather government ID, SSN/TIN, and dependent documents before starting.
  • 02
    Enter Data: Fill applicant, coverage, and payment sections using exact spellings and MM/DD/YYYY dates.
  • 03
    Attach Docs: Upload supporting documents like proof of dependent eligibility or prior coverage.
  • 04
    Sign & Submit: Apply a legally binding signature and submit to the insurer or broker for processing.

Configuring an Electronic Submission Workflow

When processing electronically, configure authentication, conditional fields, and notification settings to match insurer requirements and privacy obligations.

Field Configuration
Authentication Method Email link or SMS code; choose stronger methods for sensitive data.
Conditional Fields Show medical-history fields only when prior answers require them.
Notifications Enable email confirmations for applicant and agent once accepted.
Audit Trail Enable timestamp, IP, and action logging for legal recordkeeping.

How Electronic Submission Typically Works

Electronic enrollment follows a predictable sequence from document prep to delivery and archival.

  • Prepare Document: Upload completed form and attach supporting files.
  • Place Fields: Add signature, initial, and date fields where required.
  • Invite Signer: Send email or SMS signing link to applicant or representative.
  • Complete & Store: Signed package is returned with certificate and stored securely.

Platform Considerations for eSubmission

Confirm platform compliance with HIPAA or other industry standards before storing or transmitting protected health information.

  • Integrations: Salesforce, NetSuite, Google Workspace supported
  • Formats: PDF, DOCX, and HTML accepted
  • Authentication: Email, SMS, or advanced signer verification

Security and Compliance Essentials

Encryption: TLS 1.2/1.3 in transit; AES-256 at rest
HIPAA: Compliant with BAA required
Audit Trail: Detailed timestamps and IP addresses
Certifications: SOC 2 Type II and ISO 27001
21 CFR Part 11: Available for regulated workflows
Accessibility: WCAG 2.0 Level AA support

Common Preparation Mistakes to Avoid

  • Entering nicknames or inconsistent legal names, causing identity mismatches during underwriting and delay.
  • Providing incomplete dependent documentation or incorrect relationship information, resulting in denied dependent coverage.
  • Failing to obtain explicit consent for electronic delivery when consumer-facing disclosures are required under ESIGN.
  • Using ambiguous plan identifiers instead of exact plan codes, which can result in incorrect policy issuance.

Risks and Potential Consequences of Errors

Coverage Denial: Applications with material misstatements may be rescinded or denied
Tax Impact: Incorrect TIN may trigger backup withholding
Regulatory Fines: HIPAA violations can lead to civil penalties
Processing Delays: Missing documents slow effective date
Claim Disputes: Incomplete medical history can cause claim denials
Agent Liability: Agent errors may lead to compliance reviews

Timing, Enrollment Periods, and Processing Expectations

Know whether enrollment is subject to open enrollment, a special enrollment period, or immediate employer-sponsored effective dates to avoid missed coverage.

Open Enrollment Window:

Annual window set by plan or exchange; check plan materials for exact dates

Special Enrollment:

Triggered by qualifying life events; documentation typically due within 30–60 days

Underwriting Review:

Insurer may take 7–30 days to complete medical underwriting

Premium Payment:

Coverage may not be effective until initial premium is received

Effective Date Changes:

Requested effective dates can be limited by plan rules and enrollment timing

Key Processing Milestones from Submission to Coverage

A typical submission moves through these milestone stages from application entry to final policy delivery.

01

Submission Received

Insurer acknowledges receipt and assigns an application ID

02

Documentation Review

Underwriting or eligibility team verifies supporting documents

03

Underwriting Decision

Insurer issues acceptance, conditional acceptance, or denial

04

Policy Issuance

Final policy documents and ID cards are produced and delivered

Real-World Examples of Electronic Enrollment Use

These brief examples show how organizations rely on secure electronic signatures and workflows to process enrollment and similar forms.

Fertility Centers of Illinois

A healthcare provider streamlined patient intake with digital forms and signatures

  • Reduced wait times for documentation collection by shifting online
  • "The airSlate SignNow team has been exceptional, responsive, the API has been great, and we're extremely happy that we chose airSlate SignNow as a company."

Optica Ventures LLC

A small business used eSignature to collect benefit elections efficiently

  • Enabled remote signings for off-site employees during onboarding
  • "The interface is simple and easy-to-use for our team; more importantly, it is just as easy for our customers."

eSignature Vendor Pricing and Feature Snapshot

Compare starting prices and common capabilities across vendors. signNow is listed first. Verify final plan contents and enterprise options directly with each vendor before purchasing.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial 7-day free trial Varies by plan Varies by plan Varies by plan Varies by plan
Bulk Send Yes (plan-dependent) Yes (plan-dependent) Yes (plan-dependent) Yes (plan-dependent) Limited
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes (BAA) Yes (BAA) Yes (BAA) Varies Varies
Envelope Cap No cap 100 envelopes/user/year limit Varies Varies Varies

Frequently Asked Questions and Troubleshooting

Answers to common questions about completing, signing, and submitting the Application and Order for Health Insurance Coverage.


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