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: _______________________________________________________________________________