Form Fa-4150v - Marital Settlement Agreement - Wisconsin Circuit Court Page 8
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11Marital Settlement Agreement With Minor Children
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Case No.
_____________
M. MEDICAL AND HEALTH CARE EXPENSES
1. Medical Insurance and Payments: The parties agree that medical insurance coverage for
the minor children including medical, dental, orthodontic, hospital, psychiatric, counseling,
drug and other health expenses which is offered now or may be offered by a present or
Check a, b or c.
future employer shall be obtained and paid by:
If b or c, enter the
a.
Both parties shall provide coverage.
amount, if any, that the
b.
The wife shall provide coverage and the husband shall pay $
per month
other parent will pay.
directly to the wife to cover the difference between single and family coverage.
c.
The husband shall provide coverage and the wife shall pay $
per month
directly to the husband to cover the difference between single and family coverage.
This person shall also provide the other parent with copies of policy information and
insurance cards.
2. Uninsured Health Care Expenses: Payments for health care expenses for the minor
children not covered by insurance, including medical, dental, orthodontic, hospital,
Enter the percentage
psychiatric, counseling, drug and other health expenses shall be paid as follows:
that each parent will
a. The wife to pay
% of the total amount.
pay in a and b. The
b. The husband to pay
% of the total amount.
total must equal 100%.
3. Reimbursements: Any request for reimbursement from the other party for medical
insurance and uninsured health care expenses shall be made in writing. The other party
Enter the number of
shall pay their required percentage within
days after receiving a written request.
days for the deadline.
N. LIFE INSURANCE
Each party shall keep in full force and pay the premiums on all life insurance presently held
Check 1 or 2.
upon his or her life, naming the minor children of the parties as sole primary beneficiaries in
equal shares, until the youngest of the minor children reaches age of 18 or age 19 if they are
If 2, enter the name of
pursuing a high school diploma or its equivalent. If current coverage is lost, the party with the
the company who
current life insurance policies shall provide equivalent coverage. Each party agrees to furnish
holds the policy, the
the other with proof of the named sole primary beneficiary upon request. This provision may
policy number, and the
be satisfied in a will or trust.
name of the party who
1.
The parties do not currently have any life insurance policies in force.
the policy currently
2.
The following life insurance policies are currently in full force:
insures.
Company Name
Policy Number
Name of Insured
Neither party may borrow against any life insurance policy after the date of this agreement,
nor use it as collateral, without the written consent of the other party.
Check 1 or 2.
O. OTHER AGREEMENTS
We understand that any oral agreements are not enforceable by the court.
If 2, attach any
1.
We have no other agreements, written or oral, concerning this marriage.
additional agreements.
2.
We have additional written agreements concerning this marriage, copies of which
are attached.
P. AGREEMENTS and UNDERSTANDINGS
We understand and agree that:
•
We could each get an attorney to review this agreement.
•
This form was provided as a convenience and may NOT cover all issues.
•
This agreement may have tax consequences and that seeking tax advice is suggested.
•
We have fully disclosed each of our income, debts, assets and liabilities to each other.
•
Maintenance is deductible by the payer and taxable to the payee.
•
Child support is NOT deductible by the payer or taxable to the payee.
FA-4150V, 01/09 Marital Settlement Agreement With Minor Children
§767.34, Wisconsin Statutes
This form shall not be modified. It may be supplemented with additional material.
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