Health Insurance Agreement

Please fill in the fields below, then click on the "Print Form" button.  Once printed, complete the insurance section on the form manually.  Both parties of the case must sign this form.

Support Order Nbr: 
Plaintiff: 
Defendant: 

The parties above are in agreement that shall solely provide insurance for the child/children in this case.  Parties have agreed that an Order for Non-enforcement of Insurance be entered for