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 ____________________________________________________________and covered dependents,

(name of insured)

if any, are no longer to be covered under our group health insurance contract effective ______________________________

(date)

The reason for this termination is ______________________________________________________________________

_________________________________________________________________________________________________

(reason)

Date: ___________________________

Signature of Insured: _______________________________________________________________________________