Md. Code Regs. 31.11.03.11
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 ___________________________ |
| ___________________________________________ (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 |
Md. Code Regs. 31.11.03.11