The Essential Guide to Family & Medical Leave

appendix C | forms and checklists | 383
[date]
[employee’s name]
[employee’s address]
Notice of Termination of Group Health Coverage
Dear [employee’s name] ,
As I informed you by written notice when you first requested FMLA leave, you are
required to pay your share of the premium for group health insurance. We agreed
that you would pay these amounts by [explain method and amount—for example,
“sending me a check on the first of each month in the amount of $65.25”]. I have
attached a copy of the written notice explaining this requirement, for your reference.
[explain how payment was missed—for example, “I have not yet received your
payment that was due on May 1.”] I am writing to inform you that we are going to
terminate your health insurance coverage if we do not receive your [date of missed
payment] payment by [deadline for submitting missed payment].
Please take care of this right away. If you have any questions, feel free to call me at
[phone number].
Sincerely,
[your name]
[your title]