Letter of Inquiry and Notice of TRO/Injunction—Group Health/Dental Insurance
[Date]
[Name and address of group policyholder/plan administrator or employer]
Re: Group policy number:
Name of group member:
Social Security number of group member:
Name of nonemployee spouse:
Name[s] of minor child[ren]:
[Salutation]
I represent [name of client], the spouse of the above-referenced group member.
A divorce action is pending between my client and [his/her] spouse, [name]. You are notified that a [temporary restraining order/temporary injunction] has been issued prohibiting [name of group member] from canceling, altering, or in any manner affecting level of coverage of the [health insurance policies/dental insurance policies/health and dental insurance policies] insuring the parties [include if applicable: and their minor child[ren]]. Please notify me immediately if [name of group member] attempts to cancel, alter, or in any manner affect the above-referenced policy.
Please notify me immediately if [name of client and, if applicable, name[s] of child[ren]] [is/are] not currently qualified beneficiaries or dependents under the above-referenced policy.
Sincerely yours,
[Name of attorney]
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Forms 6-22 through 6-30 are reserved. |