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IN RE: CASE NO: FATHER: MOTHER: HEALTH INSURANCE PREMIUM WORKSHEET (HIPW) SECTION ONE: CALCULATION OF REASONABLE COST THRESHOLD FATHER MOTHER A. Parent’s Weekly Gross Income (from Line 1 of Child Support Worksheet) $ $ B. Weekly Reasonable Cost Threshold (Line A x .05) $ $ SECTION TWO: DETERMINATION OF PRIVATE HEALTH INSURANCE AVAILABLE TO THE PARENTS C. Does the parent have private health insurance, for example, employer sponsored, available for the children? If the answer is No for a parent, STOP for that parent. □ YES □ NO □ YES □ NO SECTION THREE: DETERMINATION OF WHETHER PREMIUM IS REASONABLE IN COST D. What is the weekly premium for the children’s portion only? $ $ E. TEST ONE: Is Amount on Line D equal to or less than the Amount on Line B? If the answer is No for a parent, STOP for that parent. If the answer is Yes for at least one parent, proceed to Line F for that parent(s). □ YES ⇨The premium may be reasonable in cost. □ NO ⇨The premium on Line D is not reasonable in cost. □ YES ⇨The premium may be reasonable in cost. □ NO ⇨The premium on Line D is not reasonable in cost. F. TEST TWO: Is the parent’s child support obligation from Line 4 of the Basic CSOW plus the weekly premium from Line D of the HIPW equal to or less than 50% of the Parent’s Weekly Gross Income on Line A of the HIPW? Formula: Father: Line 4, CSOW ($_____) + Line D, HIPW, ($______) = $ ______ is equal to or less than Line A, HIPW $_____ X .5 = $ ______ Mother: Line 4, CSOW ($_____) + Line D, HIPW, ($______) = $ ______ is equal to or less than Line A, HIPW $_____ X .5 = $ ______ □ YES ⇨The premium is reasonable in cost. Father may be ordered to provide health insurance. □ NO ⇨The premium on Line D is not reasonable in cost. □ YES ⇨The premium is reasonable in cost. Mother may be ordered to provide health insurance. □ NO ⇨The premium on Line D is not reasonable in cost. SECTION FOUR: ACCESSIBILITY OF THE INSURANCE G. Is the insurance coverage accessible to the children? (See Guideline 7 for defnition of accessible) □ YES □ NO □ YES □ NO SECTION FIVE: PARENT(S) ORDERED TO PROVIDE HEALTH INSURANCE H. Parent(s) for whom health insurance is reasonable and accessible □ FATHER □ MOTHER I. Parent(s) ordered to provide health insurance for children. □ FATHER $ $ □ MOTHER TOTAL ORDERED: $