Sec. 31.11.02.10. Termination Statement

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

B. If the termination statement is signed by the insured and a qualified secondary beneficiary:

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 insured)

_______________________________________________________ (signature of qualified secondary beneficiary)

C. If the termination statement is to be signed only by the insured:

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)

I affirm under penalties of perjury that the reason given in this statement is factually correct.

Date:_________________________________________________

_______________________________________________________ (signature of insured)

On this ___________________ (date) personally appeared before me ___________________________________________________ (name of insured) who affirmed under oath that the above is true to the best of his/her knowledge and belief.

_______________________________
(signature of notary public)

My appointment expires _______________________________(Notary Seal)