Qualifying Event

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
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 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 premium)		Written documentation from TennCare on company letterhead stating that coverage has been or will be terminated
Termination of Spouse’s or Ex-Spouses 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, Ex-Spouse’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