Qualifying Event

Documentation Required

Death of spouse or ex-spouse

Copy of death certification and written documentation from the employer

on company letterhead providing names of covered participants and date

coverage ends.

Divorce

Copy of the signed divorce decree and written documentation from the

employer on company letterhead providing names of covered participants,

date coverage ends, and the reason why coverage ended.

Legal separation

Copy of the agreed order of legal separation and written documentation from

the employer on company letterhead providing names of covered participants,

date coverage ends, and the reason why coverage ended.

Loss of eligibility (does not include a loss due to failure to pay premiums or termination of coverage for cause)

Written documentation from the employer or the insurance company on

company letterhead providing the names of covered participants, date

coverage ends and the reason for the loss of eligibility.

Loss of coverage due to exhausting lifetime benefit maximum

Written documentation from the insurance company on company letterhead

providing the names of covered participants, date coverage ended and stating

that the lifetime maximum has been met.

Loss of TennCare (does not include a loss due to failure to pay premiums)

Written documentation from TennCare on company letterhead stating that

coverage has been or will be terminated.

Termination of spouse’s or ex-spouse’s employment (voluntary and non-voluntary)

Written documentation from the employer on company letterhead providing

names of covered participants, date coverage ends and reason why coverage

ended.

Employer eliminated contribution to spouse’s, exspouse’s or dependent’s insurance coverage (total contribution, not partial)

Written documentation from the employer on company letterhead providing

names of covered participants, date contribution amount changed and date

coverage ended.

Spouse’s or ex-spouse’s work hours reduced causing loss of eligibility for insurance coverage

Written documentation from the employer on company letterhead providing

names of covered participants, date coverage ends and reason why coverage

ended.

OR employee without coverage or with single coverage

Acquires a new dependent — spouse

(and adding other previously eligible dependents)

Copy of marriage certificate.

Acquires a new dependent — newborn

(and adding other previously eligible dependents)

Copy of birth certificate for newborn.

Acquires a new dependent

adoption/legal custody Copy of adoption documents.