DEPARTMENT OF LABOR AND REGULATION
DIVISION OF INSURANCE
FORM FOR REPORTING
MEDICARE SUPPLEMENT POLICIES
Chapter 20:06:13
APPENDIX B
SEE: § 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
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Signature
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Name and Title (please type)
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Date
