EmailMe Form - Children Information Sheet (Insurance)

Your Name:
First Last
Yes No

Does the Mother have Access to Private Health Insurance at a Reasonable Cost to Her?
Yes No

Does the Father Have Access to Private Health Insurance at a Reasonable Cost to Him?
Is Private Health Insurance Presently In Effect for the Children?
(If No, Skip to Next Heading)
Name of Insurance Company:
Policy Number:
Party Responsible for Premium:
Monthly Cost of Premium:
Is The Insurance Coverage Provided Through a Parent's Employment? Is so, Which Parent:
Medicaid
Yes No

Are The Children Receiving Medicaid:
CHIPS
Yes No

Are the Children Receiving Health Benefit Coverage Under CHIPS (the Children's Health Insurance Program)
If Yes, What is the Cost of the Premiums:

	Yes	No
Does the Mother have Access to Private Health Insurance at a Reasonable Cost to Her?

	Yes	No
Does the Father Have Access to Private Health Insurance at a Reasonable Cost to Him?

	Yes	No
Are The Children Receiving Medicaid:

	Yes	No
Are the Children Receiving Health Benefit Coverage Under CHIPS (the Children's Health Insurance Program)