This government document is issued by Department of Child Support Services for use in California
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https://www.google.com/url?client=internal-element-cse&cx=001779225245372747843:3a1xdp1oi78&q=https://childsupport.ca.gov/wp-content/uploads/sites/252/Employers/Health-Insurance-Information.pdf&sa=U&ved=2ahUKEwiVsKSfmfbxAhXFAxAIHWDLC-I4FBAWMAR6BAgEEAI&usg=AOvVaw2Wu0KEaEV5oD6hX48MWlIw