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Chapter 24

Form 24-27

Letter to Health or Dental Insurance Company—Request for Certificate of Coverage

[Date]

[Name and address of insurance company]

Re:    Policy number:
Insured:
Beneficiary:

[Salutation]

In accordance with the order of the [designation] Court of [county] County, Texas, signed on [date], [name] is required to furnish [health/dental] insurance coverage for the ben­efit of [name[s]].

Please send me a certificate of insurance of this coverage annually. I enclose a form to be completed and returned to me.

If you have any questions about this document, please let me know. Thank you.

Sincerely yours,

   
[Name of attorney]

Enc.

INSURANCE CARRIER:       

      

POLICY NUMBER:       

NAME OF INSURED:       

NAMES OF BENEFICIARIES UNDER POLICY:       

      

DEDUCTIBLE AMOUNT:       

EFFECTIVE DATE OF POLICY:       

EXPIRATION DATE OF POLICY:       

REMARKS: