- 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) I affirm under penalties of perjury that the reason given in this statement is factually correct. 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) Date: ___________________________ ________________________________________________________________________________________________ (signature of insured) On this ___________________________ personally appeared before me ________________________________________ (date) (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)
Authority: Insurance Article, §§2-109, 15-407—15-409, and 15-412; Health-General Article, §19-703; Annotated Code of Maryland
Effective date: September 19, 1988 (15:19 Md. R. 2247)
Chapter recodified from COMAR 09.30.77 to COMAR 31.11.02 effective September 7, 1998 (25:18 Md. R. 1439)
Regulation .08 repealed effective June 22, 2015 (42:12 Md. R. 764)