.11 Termination Statement.

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 ________________________

Date: _____________________

Signature of Insured: _________________________________