Md. Code Regs. 31.11.04.11
Current through Register Vol. 52, No. 1, January 10, 2025
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: _________________________________
Md. Code Regs. 31.11.04.11