Fill and Sign the For Insurance Form

      (Name of Plaintiff)       (Address)       (Phone) ) ) ) ) ) ) ) ) ) ) ) SUPERIOR COURT OF NEW JERSEY       , CHANCERY DIVISION Plaintiff FAMILY PART,       COUNTY vs. CASE NO.             , AFFIDAVIT OF INSURANCE COVERAGE Defendant STATE OF NEW JERSEY ) )SS COUNTY OF       ) I,       , being of full age and duly sworn, according to law, upon oath, depose and say: 1. I am the Plaintiff in this case and am filing this Affidavit in support of my Complaint for Divorce. 2. The following is a complete list of all known insurance coverage of the parties, including but not limited to life, health, automobile, and homeowner's insurance. Name of Insured:       Type of Ins (circle): Life/Health/Auto/Home/Other Insurance Co. Name:       Address:       Phone:       Fax:       Policy Number:       Who Else Covered:             (If Applicable) Policy Term:       Name Beneficiary(ies):       Name of Insured:       Type of Ins (circle): Life/Health/Auto/Home/Other Insurance Co. Name:       Address:       Phone:       Fax:       Policy Number:       Who Else Covered:             (If Applicable) Policy Term:       Name Beneficiary(ies):       - 1 - Name of Insured:       Type of Ins (circle): Life/Health/Auto/Home/Other Insurance Co. Name:       Address:       Phone:       Fax:       Policy Number:       Who Else Covered:             (If Applicable) Policy Term:       Name Beneficiary(ies):       Name of Insured:       Type of Ins (circle): Life/Health/Auto/Home/Other Insurance Co. Name:       Address:       Phone:       Fax:       Policy Number:       Who Else Covered:             (If Applicable) Policy Term:       Name Beneficiary(ies):       I hereby specify that any and all cancellations or modifications made to these or any other insurance policies within the last ninety (90) days are listed below:                   All insurance identified in this affidavit shall be maintained pending further order of the court. Dated:       By: ________________________________ Plaintiff Sworn and Subscribed to before me, this       day of       , 20       . _________________________________ Notary Public of the State of New Jersey My commission expires on       . - 2 -