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)