NOTICE OF DIVORCE OR LEGAL SEPARATION

							                                                         NOTICE OF DIVORCE
     P.O. BOX 617
     CONCORD, NH 03302-0617
                                                        OR LEGAL SEPARATION
     800.527.5001
     FAX 603.226.2988                          THIS FORM MUST BE FILLED OUT BY THE SUBSCRIBER AS NOTIFICATION
     WWW.HEALTHTRUSTONLINE.ORG                 TO HEALTHTRUST OF THE COURT DECREE REGARDING INSURANCE
                                               COVERAGE FOR THE EX-SPOUSE AND THE CHILD(REN). IT MAY BE
                                               NECESSARY FOR HEALTHTRUST TO REQUEST A COPY OF THE COURT
                                               DECREE.


NAME OF SUBSCRIBER: ___________________________________________________________________________

ADDRESS: _______________________________________________________________________________________

GROUP/SECTION #: ______________________________ IDENTIFICATION #: ________________________________

I HEREBY NOTIFY HEALTHTRUST THAT I AM NOW:

            ❑ DIVORCED        ❑ LEGALLY SEPARATED                        DATE OF DECREE: _____________________

RE: FORMER SPOUSE: My former spouse was covered as an eligible dependent under my group plan through my
employer immediately prior to the issuance of such decree. The decree provides as follows with respect to the nature
and payment terms of my former spouse’s insurance coverage after the divorce/legal separation:

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

RE: CHILDREN: The child(ren) listed below were covered as eligible dependents under my group plan through my
employer immediately prior to the issuance of such decree. The decree provides as follows with respect to the nature
and payment terms of our children’s insurance coverage after the divorce/legal separation:

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

I understand that my former spouse and/or my child(ren) may be entitled to continued coverage under my employer’s
insurance plan in certain situations pursuant to state or federal law.


NAME OF FORMER SPOUSE: _______________________________________________________________________

CURRENT ADDRESS: ______________________________________________________________________________

DATE OF BIRTH: __________________________________________________________________________________

EMPLOYMENT STATUS: ____________________________________________________________________________

NAME(S) OF COVERED CHILD(REN): _________________________________________________________________

CURRENT ADDRESS: ______________________________________________________________________________

DATE(S) OF BIRTH: ________________________________________________________________________________



SIGNATURE OF SUBSCRIBER: ________________________________________________                      DATE: ______________




                              WHITE – HEALTHTRUST    YELLOW – EMPLOYER       PINK – EMPLOYEE
HT-008 (10/04)