<html> <head> <title>Rule 20:06:21:0D Rescission Reporting Form.</title> <META NAME="Keywords" Content="Administrative Rules 20:06:21:0D"> <META NAME="Description" Content="Administrative Rules 20:06:21:0D Rescission Reporting Form."> <meta http-equiv=Content-Type content="text/html; charset=windows-1252"> <meta name=Generator content="Microsoft Word 14 (filtered)"> <title>DEPARTMENT OF REVENUE AND REGULATION</title> <style> <!-- /* Font Definitions */ @font-face {font-family:Times; panose-1:2 2 6 3 5 4 5 2 3 4;} /* Style Definitions */ p.MsoNormal, li.MsoNormal, div.MsoNormal {margin:0in; margin-bottom:.0001pt; font-size:10.0pt; font-family:"Times","serif";} @page WordSection1 {size:8.5in 11.0in; margin:1.0in 1.25in 1.0in 1.25in;} div.WordSection1 {page:WordSection1;} --> </style> </head> <body lang=EN-US> <div class=WordSection1> <p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size: 12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p 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12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size: 12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size: 12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size: 12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size: 12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>DEPARTMENT OF LABOR AND REGULATION</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>DIVISION OF INSURANCE</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>RESCISSION REPORTING FORM</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>Chapter 20:06:21</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>APPENDIX D</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>SEE: &#167;</span></font><font size=3><span style='font-size:12.0pt'> </span></font><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>20:06:21:45</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size: 12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b><span style='font-weight:bold'>Source:</span></b> 23 SDR 55, effective October 20, 1996.</span></font></p> <font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'><br clear=all style='page-break-before:always'> </span></font> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>Model Regulation Service--April 1995</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>RESCISSION REPORTING FORM FOR</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>LONG-TERM CARE POLICIES</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>FOR THE STATE OF ______________</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>FOR THE REPORTING YEAR 19____</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size: 12.0pt;font-family:"Times New Roman","serif"'>Company Name: __________________________________________</span></font></p> <p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size: 12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size: 12.0pt;font-family:"Times New Roman","serif"'>Address:&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; __________________________________________</span></font></p> <p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size: 12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size: 12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp;__________________________________________</span></font></p> <p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size: 12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size: 12.0pt;font-family:"Times New Roman","serif"'>Phone Number: ___________________________________________</span></font></p> <p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size: 12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size: 12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Due: March 1 annually</span></font></p> <p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size: 12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal><b><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif";font-weight:bold'>Instructions:</span></font></b></p> <p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size: 12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>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.</span></font></p> <p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size: 12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size: 12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Date of&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Date/s</span></font></p> <p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size: 12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Policy&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Policy and&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Name of&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Policy&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Claim/s&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Date of</span></font></p> <p class=MsoNormal><u><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Form #&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Certificate #&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Insured&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Issuance&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Submitted&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Rescission&nbsp;&nbsp; &nbsp;&nbsp;&nbsp;&nbsp;</span></font></u></p> <p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size: 12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size: 12.0pt;font-family:"Times New Roman","serif"'>_______________________________________________________________________________</span></font></p> <p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size: 12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size: 12.0pt;font-family:"Times New Roman","serif"'>Detailed reason for rescission: ______________________________________________________</span></font></p> <p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size: 12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size: 12.0pt;font-family:"Times New Roman","serif"'>_______________________________________________________________________________</span></font></p> <p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size: 12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size: 12.0pt;font-family:"Times New Roman","serif"'>_______________________________________________________________________________</span></font></p> <p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size: 12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size: 12.0pt;font-family:"Times New Roman","serif"'>_______________________________________________________________________________</span></font></p> <p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size: 12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size: 12.0pt;font-family:"Times New Roman","serif"'>_______________________________________________________________________________</span></font></p> <p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size: 12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=right style='text-align:right'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>_________________________________</span></font></p> <p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size: 12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Signature</span></font></p> <p class=MsoNormal align=right style='text-align:right'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>_________________________________</span></font></p> <p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size: 12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Name and Title (please type)</span></font></p> <p class=MsoNormal align=right style='text-align:right'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>_________________________________</span></font></p> <p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size: 12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Date</span></font></p> <p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size: 12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size: 12.0pt;font-family:"Times New Roman","serif"'>Copyright NAIC 1995&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 641-31</span></font></p> </div> </body> </html>