THE FIRST $100 PER CHILD PER YEAR OF MEDICAL EXPENSES WHICH ARE NOT COVERED BY 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the case number at the top of the form. This helps in tracking your submission.
3. Fill in the name of the person providing insurance and select their relationship to the child (Obligor, Obligor’s Spouse, or Other).
4. Provide the name of the insurance company and its address, including city, state, and ZIP code.
5. Indicate the policy effective date and specify whether it is a group plan or private plan.
6. Enter the policy and/or group number along with employer details such as name, address, and phone number.
7. Repeat steps 3 to 6 for the obligee's insurance information if applicable.
8. In the section regarding medical expenses not covered by insurance, specify who will pay for the first $100 per child per year and detail any additional expense percentages for both obligor and obligee.
9. Finally, attach a copy of both sides of your insurance card as required before submitting.

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