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DEPARTMENT OF LABOR AND REGULATION

 

DIVISION OF INSURANCE

 

 

 

 

RESCISSION REPORTING FORM

 

 

Chapter 20:06:21

 

APPENDIX D

 

SEE: ยง 20:06:21:45

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

          Source: 23 SDR 55, effective October 20, 1996.


Model Regulation Service--April 1995

 

RESCISSION REPORTING FORM FOR

LONG-TERM CARE POLICIES

FOR THE STATE OF ______________

FOR THE REPORTING YEAR 19____

 

 

Company Name: __________________________________________

 

Address:                   __________________________________________

 

                            __________________________________________

 

Phone Number: ___________________________________________

 

                           Due: March 1 annually

 

Instructions:

 

The purpose of this form is to report all rescissions of long-term insurance policies or certificates. Those rescissions voluntarily effectuated by an insured are not required to be included in this report. Please furnish one form per rescission.

 

                                                                                  Date of                          Date/s

          Policy       Policy and              Name of          Policy                 Claim/s            Date of

          Form #      Certificate #           Insured                 Issuance                                Submitted       Rescission       

 

_______________________________________________________________________________

 

Detailed reason for rescission: ______________________________________________________

 

_______________________________________________________________________________

 

_______________________________________________________________________________

 

_______________________________________________________________________________

 

_______________________________________________________________________________

 

_________________________________

                                                                                             Signature

_________________________________

                                                                                             Name and Title (please type)

_________________________________

                                                                                             Date

 

Copyright NAIC 1995                                                                                                              641-31


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