This request for continued coverage must be given to the plan administrator within sixty days of the divorce, and it must be signed by the client applying for continued coverage. See the practice notes at section 23.7.
Letter to Group Health Insurance Plan—Request for Continued Coverage
[Date]
[Name and address of plan administrator]
Re: Group policy number:
Name of group member:
Request for Continued Coverage
[Salutation]
I was divorced from [name of group member] on [date] in Cause No. [number], a suit styled “[style of case],” filed in the [designation] Court of [county] County, Texas. My former spouse is a group member in the above-referenced group policy.
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Include the following for plans covered under federal law. |
I was a qualified beneficiary under the plan on the day before the divorce.
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Include the following for plans covered under Texas law. |
I was a dependent of the group member for one year before the divorce.
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Continue with the following. |
I wish to exercise my right to continued coverage under the policy. This notice is provided to you within sixty days of the divorce. Please supply me with appropriate forms for the continued coverage.
Sincerely yours,
[Name of client]