This notice, which may be provided to the plan administrator by either the group member or the dependent, is required for plans covered by the Texas Insurance Code. See the practice notes at section 23.7.
Letter to Group Health Insurance Plan—Notice of Severance of the Family Relationship
[Date]
[Name and address of plan administrator]
Re: Group policy number:
Name of group member:
Notice of Severance of the Family Relationship
[Salutation]
I was divorced from [name of former spouse] on [date] in Cause No. [number], a suit styled “[style of case],” filed in the [designation] Court of [county] County, Texas. This notice is provided to you within fifteen days of the severance of the family relationship according to the provisions of section 1251.308 of the Texas Insurance Code.
Sincerely yours,
[Name of client]