Form JD-FM-125 "Order to Maintain Health Insurance for Minor Child(Ren)" - Connecticut

What Is Form JD-FM-125?

This is a legal form that was released by the Connecticut Superior Court - a government authority operating within Connecticut. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2016;
  • The latest edition provided by the Connecticut Superior Court;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form JD-FM-125 by clicking the link below or browse more documents and templates provided by the Connecticut Superior Court.

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Download Form JD-FM-125 "Order to Maintain Health Insurance for Minor Child(Ren)" - Connecticut

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ORDER TO MAINTAIN
STATE OF CONNECTICUT
Court Use Only
SUPERIOR COURT
HEALTH INSURANCE FOR
INSURE
www.jud.ct.gov
MINOR CHILD(REN)
*INSURE*
JD-FM-125 Rev. 7-16
To be prepared by counsel or parties and submitted to the court for verification and certification.
C.G.S. 46b-84(e)
Distribution:
ORIGINAL: Court File
COPY: Custodial Parent or Custodian
Name and address of court
Docket number
Name of plaintiff
Name of defendant
Date of order
Type of case
Dissolution
Annulment
Legal Separation
Support Action
Custody Action
Case status
Custodial parent or custodian
(If joint custody, parent who maintains primary place of residence for child(ren)
Final
Post-
Pendente Lite
Judgment
Judgment
1. The above-named
plaintiff
defendant
is ordered to maintain the following health insurance coverage as available in
the manner prescribed below for the benefit of the below-named child(ren):
Medical
Dental
Hospitalization
Type of
Coverage
Other (Specify)
Available
His/her employment
His/her union
Other available group plan
Privately
Through
Name
Date of birth
Name
Date of birth
Children
To Be
Covered
The above-mentioned order of health insurance is subject to the following conditions, if any:
2. The above-mentioned health insurance coverage is to be effective on (date):
3. Said
plaintiff
defendant
is ordered to provide certification or verification of such insurance to the:
Support Enforcement Office
Family Services Office
Department of Social Services
Custodial Parent
Custodian
on or before (date):
4. It is further ordered that:
A. the signature of the custodial parent or custodian of the insured minor child(ren) shall constitute a valid authorization to the insurer for
purposes of processing an insurance reimbursement payment to the provider of the medical services or to the custodial parent or
custodian;
B. neither parent shall prevent or interfere with the timely processing of any insurance reimbursement claim; and
C. if the parent receiving an insurance reimbursement payment is not the parent who is paying the bill for the services of the medical
provider, the parent receiving such insurance reimbursement payment shall promptly pay to the parent or custodian paying such bill
any insurance reimbursement for such services.
By the Court (Print or type name of Judge/Family Support Magistrate)
Date signed
Signed (Judge, Family Support Magistrate, Clerk, Assistant Clerk)
I hereby certify that the above order is a true copy of the order requiring maintenance of health insurance for the above-
named child(ren). In testimony whereof, I have hereunto set my hand and affixed the seal of said court at the above
Certification
location on:
Date
Signed (Clerk, Assistant Clerk)
SEE IMPORTANT NOTICE TO CUSTODIAL PARENT OR CUSTODIAN ON PAGE 2
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ORDER TO MAINTAIN
STATE OF CONNECTICUT
Court Use Only
SUPERIOR COURT
HEALTH INSURANCE FOR
INSURE
www.jud.ct.gov
MINOR CHILD(REN)
*INSURE*
JD-FM-125 Rev. 7-16
To be prepared by counsel or parties and submitted to the court for verification and certification.
C.G.S. 46b-84(e)
Distribution:
ORIGINAL: Court File
COPY: Custodial Parent or Custodian
Name and address of court
Docket number
Name of plaintiff
Name of defendant
Date of order
Type of case
Dissolution
Annulment
Legal Separation
Support Action
Custody Action
Case status
Custodial parent or custodian
(If joint custody, parent who maintains primary place of residence for child(ren)
Final
Post-
Pendente Lite
Judgment
Judgment
1. The above-named
plaintiff
defendant
is ordered to maintain the following health insurance coverage as available in
the manner prescribed below for the benefit of the below-named child(ren):
Medical
Dental
Hospitalization
Type of
Coverage
Other (Specify)
Available
His/her employment
His/her union
Other available group plan
Privately
Through
Name
Date of birth
Name
Date of birth
Children
To Be
Covered
The above-mentioned order of health insurance is subject to the following conditions, if any:
2. The above-mentioned health insurance coverage is to be effective on (date):
3. Said
plaintiff
defendant
is ordered to provide certification or verification of such insurance to the:
Support Enforcement Office
Family Services Office
Department of Social Services
Custodial Parent
Custodian
on or before (date):
4. It is further ordered that:
A. the signature of the custodial parent or custodian of the insured minor child(ren) shall constitute a valid authorization to the insurer for
purposes of processing an insurance reimbursement payment to the provider of the medical services or to the custodial parent or
custodian;
B. neither parent shall prevent or interfere with the timely processing of any insurance reimbursement claim; and
C. if the parent receiving an insurance reimbursement payment is not the parent who is paying the bill for the services of the medical
provider, the parent receiving such insurance reimbursement payment shall promptly pay to the parent or custodian paying such bill
any insurance reimbursement for such services.
By the Court (Print or type name of Judge/Family Support Magistrate)
Date signed
Signed (Judge, Family Support Magistrate, Clerk, Assistant Clerk)
I hereby certify that the above order is a true copy of the order requiring maintenance of health insurance for the above-
named child(ren). In testimony whereof, I have hereunto set my hand and affixed the seal of said court at the above
Certification
location on:
Date
Signed (Clerk, Assistant Clerk)
SEE IMPORTANT NOTICE TO CUSTODIAL PARENT OR CUSTODIAN ON PAGE 2
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Notice To The Custodial Parent Or Guardian
Pursuant to Section 46b-84(e) of the Connecticut General Statutes, the custodial parent or custodian is responsible for
providing the insurer with a certified copy of the order requiring maintenance of health insurance for a minor child as well as
any subsequent modification of the order.
Health Insurance Provider Information
(Do not complete until after the court has certified the order on the reverse side.)
The information provided below is not being certified by the court and is provided for informational purposes only.
Health Insurance Provider
Group number
Membership number
Page 2 of 2
JD-FM-125 (page 2)
Rev. 7-16
ADA NOTICE
The Judicial Branch of the State of Connecticut complies with the
Americans with Disabilities Act (ADA). If you need a reasonable
accommodation in accordance with the ADA, contact a court
clerk or an ADA contact person listed at www.jud.ct.gov/ADA.
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