Sec. 31.11.04.11. Termination Statement

Latest version.

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

To ___________________________________________
(name of employer)

This is to advise that ___________________________ and
(name of insured)

covered dependants, 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: _________________________________

                    
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