Can the form be signed electronically?

Yes. Electronic signatures meet U.S. legal standards under the ESIGN Act (15 U.S.C. ch. 96) and UETA where adopted, provided intent, consent, attribution, and record retention are satisfied.

Is notarization ever required?

Not typically for standard insurance orders, but state or carrier rules can require notarization for certain authorizations or power-of-attorney; verify state and carrier requirements before relying on an e-signature alone.

What happens if names do not match?

A mismatched name between the ID, payment, and form can delay underwriting and payment processing; correct names prior to submission to avoid rework or coverage disputes.

Do I need to keep the signed form?

Yes. Retain signed originals or reproducible electronic records for the policy term plus applicable post-termination periods to satisfy audits and claims support.

How do I provide additional documents?

Attach supporting documents (loss run, prior policy, inspection reports) at submission; clearly label each attachment and reference it in the form to help underwriters locate required materials.

Who can sign on behalf of a company?

Only an authorized officer or agent with documented authority should sign. If authority is delegated, retain the delegation evidence to avoid disputes about binding authority.

Electronic Signature
Templates
Insurance
Order Insurance Form

Order Insurance Form

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

APPLICATION AND ORDER FOR HEALTH INSURANCE COVERAGE

ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address):

TELEPHONE NO.:

FAX NO. (Optional):

E-MAIL ADDRESS (Optional):

ATTORNEY FOR (Name):

SUPERIOR COURT OF CALIFORNIA, COUNTY OF

STREET ADDRESS:

MAILING ADDRESS:

CITY AND ZIP CODE:

BRANCH NAME:

PETITIONER:

RESPONDENT:

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 the filing of this application, I gave written notice to obligor of my intent to seek this order below 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:

(JUDICIAL OFFICER)

DECLARATION OF NO HEALTH INSURANCE COVERAGE

MARRIAGE OF (Last name, first name of each party):

CASE NUMBER:

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 deliver a copy of this order to the obligor. The coverage should begin at the earliest possible time consistent with group plan enrollment rules.

3. The obligor’s existing health coverage will 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 to 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 otherwise would 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 after you receive a copy of this order to object to the 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.

What the Order Insurance Form Is and when it applies

The Order Insurance Form is a standard document used by brokers, agents, and policy administrators to request, record, and authorize issuance of an insurance policy or coverage endorsement. It captures applicant identity, coverage options, payment terms, underwriting declarations, and agent authorization so carriers can process new business, endorsements, or binder requests. The form may be used for commercial or personal lines and is frequently paired with premium quotes, proof of prior coverage, and risk questionnaires needed for underwriting and issuance.

Why using a correct Order Insurance Form matters

A complete, accurate Order Insurance Form reduces processing delays, limits coverage disputes, and establishes the record needed for underwriting and claims. It documents the insured’s intent, the coverage requested, and the agent’s authority to bind or submit the risk.

Who prepares and who signs the Order Insurance Form

Typical preparers include insurance agents, brokers, risk managers, and in-house policy administrators who collect applicant data and assemble supporting documents.

Insurance agent or broker — completes applicant details, coverage selections, and signs to attest submission authority.
Named insured or authorized officer — reviews policy selections, signs to confirm coverage request and payment authorization.
Carrier underwriter or binder issuer — signs when authority to bind coverage is granted or when issuing temporary proof of insurance.

Signers commonly include the insured or authorized representative, the submitting agent, and in some cases a carrier underwriter or broker of record who confirms coverage terms.

Core parts of a professional Order Insurance Form

A well-structured form combines applicant data, coverage specifications, payment and billing instructions, underwriting disclosures, agent authorization, and signature blocks. Clear fields and concise instructions reduce back-and-forth and speed issuance.

Applicant Data

Full legal name, DBA if applicable, mailing and physical address, tax ID or SSN when required, and contact information for notices.

Coverage Details

Requested policy type, limits, deductibles, effective and expiration dates, and any endorsements or riders sought by the applicant.

Premium & Payment

Billing party, payment method, down payment amount, installment schedule, and agency commission disclosure where applicable.

Underwriting Declarations

Material facts, prior loss history, risk exposures, and any statement that could affect underwriting eligibility or premium calculation.

Agent Authorization

Broker/agent name, license number, agency information, and explicit statement of authority to bind or submit the risk on the insured’s behalf.

Signature Block

Signature lines for insured and agent, date fields, and any required witness or notary block if state or carrier rules require authentication.

Step-by-step: filling and submitting the Order Insurance Form

Follow these high-level steps to collect information, complete the form, and route it for issuance.

01

Collect applicant data: Gather IDs, prior policy info, and loss history before beginning.
02

Complete form fields: Enter applicant, coverage, and payment details accurately.
03

Attach supporting documents: Include prior policies, loss runs, and any inspection reports.
04

Route for signature: Send to the insured and agent; obtain carrier acceptance if binding.

How to configure an online Order Insurance Form workflow

Use this basic configuration to automate routing, required fields, and notifications when completing the form online.

Field	Configuration
Required fields	Full name \| policy type \| effective date
Conditional rules	Show vehicle details if policy type = auto
Signer order	Agent → Insured → Carrier underwriter
Notifications	Email alerts at each completed step

Typical submission and processing flow

This sequence describes where completed forms go and who acts on them after submission.

Agent Submission: Agent uploads or completes the form and attaches documents.
Insured Signature: Insured reviews terms, signs, and authorizes payment where required.
Carrier Review: Underwriter reviews, requests clarification, or issues binder.
Policy Issuance: Carrier issues policy documents and sends certified copies.

Digital delivery and signing considerations

Choose a platform that supports secure eSignature, audit trails, and the file formats you use.

File formats: PDF, DOCX and fillable form support
Integrations: CRM and AMS integrations (Salesforce, NetSuite, Microsoft 365)
Authentication: Email, SMS code, or advanced signer verification

Timing and processing expectations

Estimate processing times and note any common time-sensitive triggers for policy issuance or regulatory filings.

Initial processing:

1–5 business days for carrier intake and risk assignment

Underwriting review:

3–10 business days depending on complexity

Binder issuance:

Same day to 48 hours if binding authority exists

Policy documents:

3–15 business days after premium payment reconciliation

Audit window:

Carrier audits may occur within first 90 days

Key milestones from submission to issuance

Track these numbered milestones to monitor progress and trigger follow-ups as needed.

01

1. Submission Completed

Agent submits form with attachments and signature.

02

2. Insured Authorization

Insured signs and authorizes payment or binder terms.

03

3. Underwriting Decision

Underwriter accepts, requests changes, or declines risk.

04

4. Policy Issued

Carrier issues documents and sends confirmation to parties.

Frequent errors to avoid when preparing the form

Incomplete names or mismatched entity names that delay verification and payment setup
Missing prior loss history or incorrect dates that trigger underwriting exceptions
Ambiguous coverage selections (e.g., unspecified limits or deductibles) leading to rework
Failure to include required attachments such as signed disclosures or inspection reports

Consequences of errors or omissions

Coverage gaps: Claims may be denied if material facts were omitted

Premium adjustments: Carrier may retroactively change premium

Regulatory fines: State regulators can impose fines for licensing or disclosure violations

Binding disputes: Agent may lose binding authority without proper documentation

Delayed issuance: Processing delays increase operational costs

Tax withholding: Missing TIN can trigger backup withholding obligations

Common eSignature vendor comparison for signing Order Insurance Forms

These pricing and capability highlights help compare providers that support digital signing of insurance paperwork; signNow is listed first per comparative convention.

	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 trial	Varies by plan	Varies by plan	Varies by plan	Varies by plan
Bulk Send	Yes (Business Premium)	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes (BAA)	Yes (BAA)	Yes (BAA)	No	No

Frequently asked questions about the Order Insurance Form

Answers to common questions about completion, signatures, digital submission, and record retention for the Order Insurance Form.

Need help? Contact support

Can the form be signed electronically?
Yes. Electronic signatures meet U.S. legal standards under the ESIGN Act (15 U.S.C. ch. 96) and UETA where adopted, provided intent, consent, attribution, and record retention are satisfied.
Is notarization ever required?
Not typically for standard insurance orders, but state or carrier rules can require notarization for certain authorizations or power-of-attorney; verify state and carrier requirements before relying on an e-signature alone.
What happens if names do not match?
A mismatched name between the ID, payment, and form can delay underwriting and payment processing; correct names prior to submission to avoid rework or coverage disputes.
Do I need to keep the signed form?
Yes. Retain signed originals or reproducible electronic records for the policy term plus applicable post-termination periods to satisfy audits and claims support.
How do I provide additional documents?
Attach supporting documents (loss run, prior policy, inspection reports) at submission; clearly label each attachment and reference it in the form to help underwriters locate required materials.
Who can sign on behalf of a company?
Only an authorized officer or agent with documented authority should sign. If authority is delegated, retain the delegation evidence to avoid disputes about binding authority.

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