Health Insurance Notice - Tennessee
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1Court
County
State of Tennessee
(Must Be Completed)
(Must Be Completed)
File No.
(Must Be Completed)
Health Insurance Notice
Division
(Large Counties Only)
Plaintiff
(Name: First, Middle, Last) of Spouse Filing the Divorce)
Defendant
(Name: First, Middle, Last of the Other Spouse)
You must:
•
Fill out this form completely, OR ask the person in charge of employee benefits where you work to
fill it out.
•
File the copy with the Court.
•
Mail a copy to your spouse by certified mail. Keep a copy of this form for your records.
Important! Your spouse must receive this notice at least 30 days before the coverage ends.
To (Spouse’s Name):
(Spouse’s Address):
Street address or P.O. Box
City
State
Zip
From (Your Name):
(Your Address):
Street Address or P.O. Box
City
State
Zip
Fill out the Certificate of Service section
If you do not have health insurance, check here.
below, mail a copy of the form to your spouse, and file this form with the clerk’s office.
If you do have health insurance, fill out the information about your health insurance policy that
covers your spouse now:
Health Insurance Company:
Policy Number:
(Employee Benefits Contact Person): (Name/Phone #/Street Address/City/State/Zip)
Check one:
This policy has COBRA. That means the dependent spouse can keep the insurance after the
divorce. BUT s/he must apply by the deadline and pay the premiums and any administrative
charges. To learn more, speak to the employee benefits person listed above.
This is a group insurance policy. The dependent spouse may be able to continue coverage under
TCA § 56-7-2312(d)(1). To learn more, speak to the employee benefits person listed above. The
dependent spouse may also get insurance from another source.
This policy does not offer COBRA. That means the dependent spouse’s coverage will end after
the divorce. The dependent spouse must get other health insurance to be covered.
My spouse is not covered by my policy.
Certificate of Service:
I hereby certify that a true and exact copy of this Health Insurance Notice was mailed to my insured
spouse on
(Date)
.
I sent it to the address listed above by certified mail.
(MM/DD/YYYY)
Sign Here:
Date
___
(MM/DDD/YYY)
March 2012
(Form 4) Health Insurance Notice for Divorcing Spouses
Page 1 of 1
Approved by the Tennessee Supreme Court
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