Code of Maryland Regulations
Title 31 - MARYLAND INSURANCE ADMINISTRATION
Subtitle 11 - HEALTH INSURANCE - GROUP
Chapter 31.11.03 - Group Health Insurance - Continuation of Coverage of Surviving Spouses
Section 31.11.03.11 - Termination Statement
Universal Citation: MD Code Reg 31.11.03.11
Current through Register Vol. 51, No. 19, September 20, 2024
The termination statement shall be in language substantially as indicated in this regulation:
| 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 qualified secondary beneficiary |
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