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DEPARTMENT OF LABOR AND REGULATION

 

DIVISION OF INSURANCE

 

 

 

 

FORM FOR REPORTING

MEDICARE SUPPLEMENT POLICIES

 

 

Chapter 20:06:13

 

APPENDIX B

 

SEE: ยง 20:06:13:53

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

          Source: 18 SDR 225, effective July 17, 1992; 39 SDR 10, effective August 1, 2012.


APPENDIX B

 

FORM FOR REPORTING

MEDICARE SUPPLEMENT POLICIES

 

 

Company Name:         ______________________________

 

Address:                      ______________________________

 

                                    ______________________________

 

Phone Number:           ______________________________

 

                                                                                                            Due March 1, annually

 

The purpose of this form is to report the following information on each resident of this state who has in force more than one Medicare supplement policy or certificate.  The information is to be grouped by individual policyholder.

 

                         Policy and                                                                  Date of

                        Certificate #                                                                Issuance




 




 




 




 

 

                                                                                    ___________________________________

                                                                                    Signature

 

                                                                                    ___________________________________

                                                                                    Name and Title (please type)

 

                                                                                    ___________________________________

                                                                                    Date

 


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