MN-8377D free printable template

STATE OF MINNESOTA COUNTY OF DISTRICT COURT JUDICIAL DISTRICT FAMILY COURT DIVISION Court File No. In Re the Marriage of Petitioner QUALIFIED MEDICAL CHILD SUPPORT ORDER AND Respondent This order is intended to be a Qualified Medical Child Support Order under Section 609 a of the Employee Retirement Income Security Act of 1974 as amended. This Order supersedes all previously filed Orders in this matter relating to this subject. This includes signing all documents which may be Medical Child...Support Order. For this purpose this Court expressly reserves jurisdiction over the dissolution proceeding involving the parents of the Alternate Recipients. CONTINUED JURISDICTION In the event the Plan Administrator determines that this Order is not a Qualified Medical Child Support Order both parties shall cooperate with the Plan Administrator to make the changes necessary for it to become a qualified order. -2- DURATION The coverage of the Alternate Recipients under the Plans will begin...immediately upon qualification of this Order as a Qualified Medical Child Support Order and shall continue as long as both the Participant and each Alternate Recipient remain eligible for such coverage under the terms of such Plans. DETERMINATION BY PLAN ADMINISTRATORS -3- copy of this Order to the Plan Administrator. For the purpose of determining whether this Order is a Qualified Medical Child Support Order the Plan Administrator is advised that this Order provides for health benefit coverage...with respect to a child of a participant under a group health plan relates to benefits under such a plan and is made pursuant to the domestic relations law of this State. PLAN This Order applies to the following group health care benefits plans sponsored by Employer s Name. Medical Plan Dental Plan List Others PARTICIPANT The employee named in this paragraph Participant is a participant in the Plans identified above. The name address and Social Security number of the Participant are as follows...Name Address Social Security No* ALTERNATE RECIPIENTS -1- Date of Birth TYPE OF COVERAGE The Alternate Recipients shall receive the following benefits under the Plans identified above Dental Plan Family coverage under the option presently available. Other Describe. If the above Plans are changed so that the benefits described in this paragraph are no longer available the Alternate Recipients shall be entitled to family coverage under the most comparable taking into account deductibles...co-payments limitations on benefits and type of benefits plan offered by the Plan sponsor. This order shall lapse as it applies to each Alternate Recipient upon said Alternate Recipient attaining the age of 18 18 or age twenty 20 if the child is still attending high school or until the minor child is emancipated self-supporting married in the armed services of the United States deceased or until further Order of the Court whichever first occurs. PAYMENT INFORMATION Unless assigned to the...providers of the health care services the Plans will make all payments of benefits for services rendered to an Alternate Recipient to The Plans and their administrators are authorized to disclose all information about the benefits of the Alternate Recipients to the individual designated in this paragraph.