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STATE OF MINNESOTA DISTRICT COURT COUNTY OF __________ __________ JUDICIAL DISTRICT FAMILY COURT DIVISION In Re the Marriage of: Court File No. __________ __________, Petitioner, NOTICE TO MEDICAL INSURANCE PROVIDER AND __________, Respondent, TO: {Full Name of Group Health Plan, Address) I, {Full Name}, am a former spouse of {Full Name of Former Spouse}On {Date before date of divorce}, I was covered under the {Full Name of Group Health Plan)mainta ined by [{Full Name of Former Spouse}. Pursuant to the attached Findings of Fact, Conclusions of Law, Order for Judgment and Judgment and Decree of {Date decree was signed}, entered in {Name of case as it appears on the decree}, {Number of the case}, you are hereby advised that I request continuation coverage. Dated_______________ ______________________________ {Name of Client} Address: _______________ _______________ _______________

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