The termination statement shall be in language substantially as indicated in this regulation. To _____________________________________________________________________________________________ (name of employer) This is to advise that ____________________________________________________________and covered dependents, (name of insured) 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: _______________________________________________________________________________

Authority: Insurance Article, §§2-109, 14-124(b), and 15-409; Health-General Article, §19-703; Annotated Code of Maryland

Effective date: December 14, 1987 (14:25 Md. R. 2659)

Regulation .10 amended effective April 27, 1992 (19:8 Md. R. 804)

Chapter recodified from COMAR 09.30.84 to COMAR 31.11.04 effective September 7, 1998 (25:18 Md. R. 1439)

Regulation .01 amended effective September 27, 2004 (31:19 Md. R. 1434)

Regulation .02B amended effective September 27, 2004 (31:19 Md. R. 1434)

Regulation .08 repealed effective June 22, 2015 (42:12 Md. R. 764)