FOR CLERK'S USE ONLY
NOTICE OF YOUR RIGHTS ABOUT HEALTH INSURANCE COVERAGE WHEN A PETITION FOR DISSOLUTION (DIVORCE) IS FILED (A.R.S. §20-1377 AND §20-14084) CASE NO.____________________
WARNING: THIS IS AN IMPORTANT LEGAL NOTICE. YOUR RIGHTS TO HEALTH INSURANCE COVERAGE COULD BE AFFECTED AFTER YOUR DIVORCE IS FINAL. READ THIS NOTICE CAREFULLY. IF YOU DO NOT UNDERSTAND THIS NOTICE, YOU SHOULD CALL AN ATTORNEY FOR ADVICE ABOUT YOUR LEGAL RIGHTS AND OBLIGATIONS.
IMPORTANT INFORMATION IF YOU ARE ON YOUR SPOUSE'S INSURANCE PLAN: When a Petition for Dissolution of Marriage (papers for a divorce decree) is filed, you and/or your children may continue to be covered under your spouse's health insurance policy. Arizona law allows the dependent spouse and/or children to continue to be covered, but you must take some steps to protect your rights. WHAT INSURANCE COVERAGE APPLIES TO YOU, AND HOW TO GET IT: If you are covered by your spouse's health insurance, and you want to continue to be covered after the divorce is final, you must contact the insurance company as soon as possible, and you must start to pay the monthly insurance premium within 31 days of the date the insurance would otherwise stop. If you decide you want to be covered, the insurer can choose whether to continue coverage under the current policy, or to change the policy to your name. If the policy is changed to your name, it is called a "converted" policy. If the policy is converted by the insurer, the insurer must provide to you the same or the most similar level of coverage available, unless you ask for a lower level of coverage. WHAT COVERAGE APPLIES TO YOUR CHILDREN: If you choose to continue coverage as a dependent spouse, you can also choose to continue coverage for your dependent children if you are responsible for their care or support. PREEXISTING CONDITIONS OR EXCLUSIONS FROM INSURANCE COVERAGE: Whether the insurance is continued or converted, the insurance must be provided to you without proof of insurability and without exclusions for coverage other than what was previously excluded before the insurance was continued or converted. LIMITS ON RIGHTS TO INSURANCE COVERAGE FOR YOU AND YOUR CHILDREN: You may not be entitled to continued or converted coverage if you are eligible for Medicare or for coverage by other similar types of insurance which together with the continued coverage would make you over-insured. However, dependent children of a person who is eligible for Medicare may be covered by a continuance or a conversion. If you have questions about coverage, check with the insurer and/or the spouse's employer. WARNING TO THE SPOUSE FILING THE PETITION FOR DISSOLUTION (DIVORCE): This Notice must be served on your spouse together with the Petition for Dissolution, the Summons, and the Preliminary Injunction.
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