Certificate Of Insurance Coverage Template - Free Download
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Certificate Of Insurance Coverage Template
Certificate Of Insurance Coverage Template
____________________________________
: SUPERIOR COURT OF NEW JERSEY
: CHANCERY DIVISION: FAMILY PART
Plaintiff, : __________ COUNTY
: DOCKET NO.
:
: Civil Action
:
: CERTIFICATION OF INSURANCE
Defendant. : COVERAGE PURSUANT TO
____________________________________: R. 5:4-2(f)
I, _________, residing at ____________________________________________, certify:
I am the ___(Plaintiff or Defendant)____the above-captioned matter. Pursuant to R. 5:4-2(f) I
submit this Certification of Insurance Coverage, which specifies all insurance coverage relating
to the above-captioned parties and our minor child.
To the best of my knowledge, information and belief, none of the insurance policies listed below
were cancelled or modified within 90 days before the date of this certification.
LIFE INSURANCE
Company Name:
Company Address:
Company Phone Number:
Policy Owner:
Policy Number:
Beneficiary:
Face Amount ($):
Policy Term (if applicable):
HEALTH INSURANCE
Name of Insured:
Company Name:
Company Address:
Company Phone Number:
ID Number:
Group Number:
Persons Covered:
Coverage Type:
[] Made available through Employment
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