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Revised 7/1/08 1 STATE OF TENNESSEE COURT: COUNTY : NOTICE REGARDING INSURANCE COVERAGE OF SPOUSES AND FORMER SPOUSES FILE#: DIVISION PLAINTIFF: DEFENDANT: TO: ______________________ Insured Spouse ______________________ ______________________ Last known address Notice is hereby provided to you, pursuant to T.C.A. ' 56-7-2366, with regard to your medical (accident and sickness) insurance, the following information: 1. You are currently insured under the following policy, of which your spouse/participant is the insured or policy holder, which provides medical and/or hospital insurance for your benefit: Insurance company: ________________________________ Policy number: ________________________________ 2. You are receiving this notice because your insurance coverage through your spouse’s insurance provider will terminate as a result of a divorce, a legal separation or other separation. 3. Your spouse is hereby informing you that the insurance coverage will terminate 30 days from the divorce, legal separation or other separation. Unless you pursue alternative coverage options, you will be without health insurance coverage. CHECK IF APPLICABLE: [ ] This policy has a COBRA continuation provision. This permits you to continue coverage under the existing policy if certain steps are timely taken, which may include the completion of a cobra benefits application and the payment, in advance, of premiums. The contact person for COBRA information is as follows: Person/Plan Administrator: ________________________________ Phone Number: ________________________________ Revised 7/1/08 2 Address: ________________________________ ________________________________ [ ] COBRA coverage is not available under this policy. Therefore, to have health insurance, you must obtain your own insurance from another source. [ ] The insurance coverage you currently have is a group insurance policy and you may be entitled to continuation coverage pursuant to T.C.A. ' 56-7-2312(d)(1). The person to contact for insurance continuation information is: Person/Plan Administrator: ________________________________ Phone Number: ________________________________ Address: ________________________________ ________________________________ Alternatively, know that you may obtain insurance from another source of your choice. Dated this day of ________________, 200_. _______________________________ Insured spouse/participant or policy holder _______________________________ _______________________________ Address _______________________________ Attorney for insured spouse/participant or policy holder (if applicable) CHECK IF APPLICABLE: [ ] A divorce or legal separation has been filed in the above-captioned court. CERTIFICATE OF SERVICE (Dependent Spouse has legal representation) I hereby certify that a true and exact copy of the foregoing document was properly mailed to or served upon the dependent insured spouse, through his/her attorney of record, _______________________ , by hand delivery or first class mail with sufficient postage. THIS _____ day of ___________________ , 200_. BY: _____________________________ Attorney for Insured/Participant/Policy Holder OR Insured/Policy Holder Revised 7/1/08 3 CERTIFICATE OF SERVICE (Dependent Spouse does not have legal representation) I hereby certify that a true and exact copy of the foregoing document was properly mailed to or served upon the dependent insured spouse, by hand delivery or first class mail with sufficient postage AND was properly mailed to dependent insured spouse by certified mail. THIS _____ day of ___________________ , 200_. BY: _____________________________ Attorney for Insured/Participant/Policy Holder OR Insured/Policy Holder [ ] A divorce or legal separation has NOT been filed in the above-captioned court. CERTIFICATE OF SERVICE (Dependent Spouse has legal representation) I hereby certify that a true and exact copy of the foregoing document was properly mailed to or served upon the dependent insured spouse, through his/her attorney of record, _______________________ , by hand delivery or first class mail with sufficient postage. THIS _____ day of ___________________ , 200_. BY: _____________________________ Attorney for Insured/Participant/Policy Holder OR Insured/Policy Holder CERTIFICATE OF SERVICE (Dependent Spouse does not have legal representation) I hereby certify that a true and exact copy of the foregoing document was properly mailed to or served upon the dependent insured spouse by hand delivery or first class mail with sufficient postage, AND was properly mailed to the dependent insured spouse by certified mail. THIS _____ day of ___________________ , 200_. BY: _____________________________ Attorney for Insured/Participant/Policy Holder OR Insured/Policy Holder
