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    FL 470ATTO RNEY O R P AR TY W IT H O UT A TTO RNEY ( N am e, s ta te b ar n um ber, a nd a ddre ss):FORCOURTUSEONLYT E LE PH O NE N O .FA X N O .ATTO RNEY F O R ( N am e):S U PER IO R C O URT O F C ALIF O RNIA , C O UNTY O FSTR EET A D DR ESSM AIL IN G A D D RESSC IT Y A N D Z IP C O DEBR AN CH N AM EM ARRIA G E O FPETIT IO NER :RESPO NDEN T:CASE N UM BERA PPLIC ATIO N A ND O RDER F O R H EA LTH I N SU RANCE C O VER AG EAPPLIC ATIO N1. On (date): , t h is c o urt o rd ere d o blig or ( n am e): to p ro vid e h ealt h in su ra nce c o ve ra g e f o r t h e c h ild re n n am ed in t h e o rd er b elo w . 2. a .O n ( d ate ): , w hic h is a t le ast 1 5 d ays b efo re f ilin g t h is a pplic a tio n, I g ave w rit te n n otic e t o o blig or o f m y in te nt t o s e ek t h is o rd er by f ir s t- c la ss m ailb y p ers o nal s e rv ic e .O Rb.O blig or h as w aiv e d t h e r e quir e m ent o f w rit te n n otic e .3. 1 a sk t h e c o urt t o o rd er t h e e m plo ye r o r o th er p ers o n p ro vid in g h ea lt h in su ra nce c o ve ra ge t o e nro ll o r m ain ta in t h e c h ild re n in a ny healt h in su ra n ce c o ve ra ge a va ila ble t o t h e o blig or.I d ecla re u nder p e nalt y o f p erju ry u nder t h e la w s o f t h e S ta te o f C alif o rn ia t h at t h e f o re goin g is t r u e a nd c o rre ct.D ate :(T Y PE O R P R IN T N AM E)(S IG NATU RE O F A PPLIC AN T)O RDER F O R H EA LTH I N SU RA NCE C O VER AG E ( A SSIG NM EN T)To e m plo yer o r o th er p ers o n p ro vid in g h ealt h i n su ra n ce c o vera g e f o r o blig or ( n am e): So cia l S ecu rit y N um ber ( if k n ow n):Y O U A RE O RDER ED T O1. B egin o r m ain ta in h ealt h in su ra n ce c o ve ra ge o f: Na m e o f c h ildD ate o f b ir thS ocia l S ecu rit v N o.Y ou m ay d educt a n y p re m iu m o r c o sts f r o m t h e w ages o r e arn in gs o f o blig or.2 . I f t h e o b lig or w ork s f o r y o u o r if y o u p ro vid e h ealt h in su ra nce c o ve ra ge t o o blig or, g iv e h im o r h er a c o py o f t h is o rd er w it h in 1 0 d aysa fte r y o u r e ce iv e it .3 . I f n o h e alt h in su ra nce c o ve ra ge is a va ila ble t o t h e o blig or, c o m ple te a nd s ig n t h e D ecla ra tio n o f N o H ealt h I n su ra nce C ove ra ge o nth e r e ve rs e a nd m ail t h is f o rm w it h in 2 0 d ays t o t h e a tto rn ey o r p ers o n r e questin g t h e a ssig nm ent.D ate :(J U DG E O F T H E S U PER IO R C O URT)A PPLIC ATIO N A ND O RDER F O R HEA LTH I N SU RANCE C O VER AG EFam ily C ode, § § 3 760-3 77 2Form Adopted by for Optional Use Judicial Council of California FL-470 [Rev. January 1, 2007]ele ctr o nic f o rm  2 006- 7 WWW.LawCA.com La w P ublis h erspage1 of 2 M AR RIA G E O F ( la st n am e, fir s t n am e o f p artie s):C ASE N UM BERD EC LA RATIO N O F N O H EA LTH I N SU RANCE C O VER AG ENo h ealt h in su ra nce c o ve ra ge is a va ila ble t o t h e o blig or ( n am e): be ca use ( s ta te r e aso ns):I d ecla re u nder p e nalt y o f p erju ry u nd er t h e la w s o f t h e S ta te o f C alif o rn ia t h at t h e f o re goin g is t r u e a nd c o rre ct.D ate :(T Y PE O R P R IN T N AM E A N D T IT LE )(S IG NATU RE O F E M PLO YER O R P ER SO N P R O VID IN G H EALT H IN SU RAN CE)M AIL A C O PY O F T H IS D EC LA R ATIO N W IT H IN 2 0 D AYS T O T H E A TTO RNEY O R P ER SO N S EEKIN G T H IS E N RO LLM EN T (SEE I N STR UCTIO N N O . 5 , B ELO W ). IN STR UCTIO NS FO R E M PLO YER O R O TH ER P ER SO N P R O VID IN G H EA LTH I N SU RANCE These in str u ctio ns a pply o nly t o a n O rd er f o r H ealt h I n su ra nce C ove ra ge is su ed b y a c o urt.1 . I f t h e o b lig or w ork s f o r y o u o r is c o ve re d b y h ealt h in su ra nce p ro vid ed b y y o u, y o u m ust g iv e h im o r h er a c o py o f t h is o rd er w it h in 10 d ays a fte r y o u r e ce iv e it .2 . U nle ss y o u r e ce iv e a m otio n t o q ua sh t h e a ssig nm ent, y o u m ust t a ke s te ps t o b egin o r m ain ta in c o ve ra ge o f t h e s p ecif ie d c h ild re nw it h in 3 0 d ays a fte r y o u r e ce iv e t h is o rd er. T he c o ve ra ge s h ould b egin a t t h e e arlie st p ossib le t im e c o nsis te nt w it h g ro up p la n enro llm ent r u le s.3 . T he o blig or's e xis tin g h ealt h c o ve ra ge s h all b e r e pla ce d o nly if t h e c h ild re n a re n ot p ro vid ed b enefit s u nder t h e e xis tin g c o ve ra ge where t h ey r e sid e.4 . I f t h e o b lig or is n ot e nro lle d in a p la n a nd t h ere is a c h oic e o f s e ve ra l p la ns, y o u m ay e nro ll t h e c h ild re n in a ny p la n t h at w ill re aso nably p ro vid e b enefit s o r c o ve ra ge w here t h ey liv e , u nle ss t h e c o urt h as o rd ere d c o ve ra ge b y a s p ecif ic p la n.5 . I f n o c o ve ra ge is a va ila ble , c o m ple te t h e D ecla ra tio n o f N o H ealt h I n su ra nce C ove ra ge a t t h e t o p o f t h is p age a nd m ail t h edecla ra tio n b y f ir s t- c la ss m ail t o t h e a tto rn ey o r p ers o n s e ekin g t h e a ssig nm ent w it h in 2 0 d ays o f y o ur r e ce ip t o f t h is o rd er. K eep a co py o f t h e f o rm f o r y o ur r e co rd s.6 . I f c o ve ra ge is p ro vid ed, y o u m ust s u pply e vid ence o f c o ve ra ge t o b oth p are nts a nd a ny p ers o n h avin g c u sto dy o f t h e c h ild .7. U pon r e quest o f t h e p are nts o r p ers o n h avin g c u sto dy o f t h e c h ild , y o u m ust p ro vid e a ll f o rm s a nd o th er d ocu m enta tio n n ece ssa ry fo r s u bm it tin g c la im s t o t h e in su ra nce c a rrie r t o t h e e xte nt y o u p ro vid e t h em t o o th er c o ve re d in div id uals .8 . Y ou m ust n otif y t h e a pplic a nt o f t h e e ffe ctiv e d ate o f t h e c o ve ra ge o f t h e c h ild re n.9. Y ou w ill b e lia ble f o r a ny a m ounts in cu rre d f o r h ealt h c a re s e rv ic e s t h at w ould o th erw is e h ave b een c o ve re d u nder t h e in su ra ncep olic y if y o u w illf u lly f a il t o c o m ply w it h t h is o rd er. Y ou c a n a ls o b e h eld in c o nte m pt o f c o urt. C alif o rn ia la w f o rb id s y o ur f ir in g o r takin g a ny d is cip lin ary a ctio n a gain st a ny e m plo ye e b eca use o f t h is o rd er.E M PLO YEE I N FO RM ATIO N1. T his o rd er t e lls y o ur e m plo ye r o r o th er p ers o n p ro vid in g h ealt h in su ra nce c o ve ra ge t o y o u t o e nro ll o r m ain ta in t h e n am ed c h ild re nin a h ealt h in su ra nce p la n a va ila ble t o y o u a nd t o d educt t h e a ppro pria te p re m iu m o r c o sts , if a ny, f r o m y o ur w ages o r o th er com pensa tio n.2 . Y ou h ave 1 5 d ays t o c o nte st t h is o rd er. F am ily C ode s e ctio n 3 765 t e lls y o u h ow . 3. F am ily C ode s e ctio n 3 770 t e lls y o u h ow a nd w hen t o p etit io n t h e c o urt t o e nd t h is a ssig nm ent.A PPLIC ATIO N A ND O RDER F O R HEA LTH I N SU RANCE C O VER AG EPage 2 o f 2FL-470 [Rev. January 1, 2007]