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Tennessee Health Insurance Notice

In the case of a divorce, the Health Insurance Notice form is used to determine the health insurance state of the marriage after it has been terminated and deciding who will and who will not be covered after the divorce is completed. The following form has to be completed by both spouses.

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March 2012  (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 to 
f ill 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 N ame):  	 	
 
      (Spouse’s A ddress):  	 	
                  Street address or P.O. Box  City                     State  Zip 	
From (Your N ame):     	 	
 
     (Your Address):    	 	
               Street Address or  P.O. Box   City                     State  Zip 
 	
If you do not have health insurance, check here.   		   Fill out the Certificate of Service section 	
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 N umber:  	 	
     	 	
(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)    	.  (MM/DD/YYYY)	 I sent it to the address listed above by certified mail. 	
Sign H ere:       	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)
Next: Tennessee Divorce Complaint Form Previous: Tennessee Divorce Decree Form
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