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: