Regulation .11 Termination Statement.

The termination statement shall be in language substantially as indicated in this regulation:

To _____________________________________________________________________________________________

(name of employer)

This is to advise that _______________________________________________________________________________

_______________________________________________________________________________________________

(name or names of qualified secondary beneficiaries)

is/are no longer to be covered under our group health insurance contract effective ________________________________

(date)

The reason for this termination is ______________________________________________________________________

_________________________________________________________________________________________________

(reason)

Date: ___________________________

____________________________________________________________________________________________

(signature of qualified secondary beneficiary)