Fill and Sign the Employers Health Insurance Return California Form

FL-475 PETITIONER/PLAINTIFF: ––––– ––––– RESPONDENT/DEFENDANT: ––––– CASE NUMBER: ––––– EMPLOYER'S HEALTH INSURANCE RETURN 1. Name of parent employee: ––––– 2. Home address of absent parent employee: ––––– Not known ––––– ––––– ––––– 3. The employee has no insurance policies for health care, vision care, or dental care through this employment. 4. The employee has the following insurance policies covering health care, vision care, and dental care: Company Type of policy Policy No. Persons insured ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– Date: ––––– ––––– (TYPE OR NAME OF EMPLOYER) (SIGNATURE OF EMPLOYER) Address: ––––– ––––– Telephone No.: ––––– 5. Return this completed return to the following district attorney within 30 days (name and address of district attorney) : ––––– ––––– ––––– If any insurance coverage lapses, complete the notice below and return a copy to the same district attorney. NOTICE OF LAPSE IN HEALTH INSURANCE 6. The health insurance listed on the Employer's Health Insurance Return above has lapsed terminated FOR (check one) : a. all persons insured for the following reason (specify) : ––––– ––––– ––––– ––––– b. the following person (name) : ––––– for the following reason (specify) : ––––– ––––– ––––– ––––– ––––– ––––– Date: ––––– ––––– (TYPE OR PRINT NAME) (SIGNATURE OF EMPLOYER) Address: ––––– ––––– ––––– Telephone No.: ––––– page 1 of 1 EMPLOYER'S HEALTH INSURANCE RETURN Family Code, §§ 3771, 3772el ectr onic form ã 2002 WWW.LawCA.co m L a w P u b l i s h e r sForm Adopted by for Manditory Use Judicial Council of California FL- [Rev. January 1, 2003]