Form 1 - Request For Divorce (Complaint) Page 18
ADVERTISEMENT
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33Court
County
State of Tennessee
(Must Be Completed)
(Must Be Completed)
File No.
Health Insurance Notice
(Must Be Completed)
(Form 4)
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 insurance coverage ends.
Most courts require you to send this to your spouse before you can get a hearing date.
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 paper to your spouse. File this form with the court clerk’s office.
If you do HAVE health insurance that covers your spouse now, check here. Then 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 your spouse can keep the insurance after the divorce. BUT
s/he must apply by the deadline and pay the premiums and any fees.To learn more, speak to the
employee benefits person listed above.
This is a group insurance policy. Your spouse might be able to continue coverage under TCA
Your
§56-7-2312(d)(1). To learn more, speak to the employee benefits person listed above.
spouse may also get insurance somewhere else.
This policy does not offer COBRA. That means your spouse will lose this insurance after the
divorce. Your spouse must get health insurance somewhere else.
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)
July 2017
(Form 4) Health Insurance Notice for Divorcing Spouses
Page 1 of 1
Approved by the Tennessee Supreme Court
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal