Health Insurance Notice {Form 4}

(Form 4) Health Insurance Notice for Divorcing Spouses Page 1 of 1 Approved by the Tennessee Supreme Court You must:Fill out this form completely, OR ask the person in charge of employee benefits where you work tofill 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 (Spouse222s Name): (Spouse222s Address): Street address or P.O. Box CityState Zip From (Your Name): (Your Address): Street Address or P.O. Box City State Zip If you do have health insurance, check here.belowail a copy of the to your spouseile this form with the clerk222s office. If you do 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 spouse can keep the insuranceafterthedivorce. BUTs/he must apply by the deadline and pay the premiums and anyTo learn more, speak to theemployee benefits person listed above. This is a group insurance policy.spouse be able to continuecoverageunderTCA24756-7-2312(d)(1). To learn more, speak to the employee benefits personlistedabove. spousemay also get insurance This policy does not offer COBRA. That means 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 insuredspouse on (Date) . (MM/DD/YYYY) I sent it to the address listed above by certified mail. Sign Here: Date (MM/DDD/YYY) State of Tennessee Court (Must Be Completed) County (Must Be Completed) Health Insurance Notice File No. (Must Be Completed) Division (Large Counties Only) Plaintiff (Name: First, Middle, Last) of Spouse Filing the Divorce) Defendant (Name: First, Middle, Last of the Other Spouse) American LegalNet, Inc. www.FormsWorkFlow.com