Notice Regarding Insurance Coverage Of Spouses And Former Spouses

Notice Regarding Insurance Coverage of Spouses and Former Spouses TO: ______________________ Insured Spouse Docket No. ___________ ______________________ ______________________ 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 is the insured or policy holder, which provided medical and/or hospital insurance for your benefit: Insurance company: ________________________________ Policy number: ________________________________ 2. You will no longer have medical or hospital insurance coverage as a dependent under this policy thirty (30) days after your divorce or legal separation order is entered. Unless you take action, you will be without health insurance coverage. Check if applicable: 3. [ ] 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: Phone Number: Address: ________________________________ ________________________________ ________________________________ ________________________________ American LegalNet, Inc. www.FormsWorkFlow.com [ ] 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: Phone Number: Address: ________________________________ ________________________________ ________________________________ ________________________________ 4. It is estimated that your premium for continued Cobra coverage will be ___________ per month. Alternatively, know that you may obtain insurance from another source of your choice. Dated this day of ________________, 200_. _______________________________ Insured spouse or policy holder _______________________________ _______________________________ Address _______________________________ Attorney for insured spouse or policy holder (if applicable) American LegalNet, Inc. www.FormsWorkFlow.com CERTIFICATE OF SERVICE 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, AND was properly mailed to the dependent insured spouse by certified mail. THIS _____ day of ___________________ , 200_. BY: _____________________________ Attorney for Insured spouse or policy holder OR Insured/Policy Holder American LegalNet, Inc. www.FormsWorkFlow.com