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Craven County Child Support Enforcement
Craven County Child Support Enforcement
Craven County Child Support Enforcement
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Craven County Child Support Enforcement

Verification of Medical Coverage Form

Please report changes, such as a lapse in coverage or termination of employment, in health insurance. We appreciate your help in ensuring that children have adequate health care.

Thank you in advance for your cooperation.

Person Completing the Form
Your Name:  First:    
Last:  
Are you the: (Please select one)  
Non-Custodial Parent (NCP) Information
NCP Name:  First:  
Last:  
Is NCP a Current Employee?   
If the NCP is no longer employed with your company, please provide the employee's last date of employment and last known address in the spaces provided below
Date of Last Employment: // (MM/DD/YYYY ie 12/22/2001)
NCP Home (or Last Known) Address 
Address 1:  
Address 2:
City:  
State:
Zip Code:  -  
Phone: ()  - 
Children Future Coverage Effective Date: // (MM/DD/YYYY ie 12/22/2001)
Other Information:
Children Covered by Insurance
Child #1  Name:    
Date of Birth: 
//  
Child #2  Name:    
Date of Birth: 
// 
Child #3  Name:    
Date of Birth: 
// 
Child #4  Name:    
Date of Birth: 
// 
Child #5  Name:   
Date of Birth: // 
Policy Information for Covered Children
Type of Insurance Coverage: (e.g. dental only, major medical, etc.)
Insurance Company:
Address 1:
Address 2:
City:
State:
Zip Code:  - 
Policy/Certificate Number:
Policy Begin Date: // (MM/DD/YYYY ie 12/22/2001)
Policy End Date: // (MM/DD/YYYY ie 12/22/2001)
Policy Owner Name:
Employer and/or Group Name:
Employer Group Number:
Children Not Covered by Insurance
Child #1 Name: Name:    
Date of Birth: 
// 
Child #2 Name: Name:    
Date of Birth: 
// 
Child #3 Name: Name:   
Date of Birth: 
// 
Child #4 Name: Name:    
Date of Birth: 
/ /  
Child #5 Name: Name:   
Date of Birth: 
// 
Contact Information
Email Address: