<html xmlns="http://www.w3.org/1999/xhtml"><head><meta charset="UTF-8" /><title></title><meta name="Generator" content="PowerTools for Open XML" /><style>span { white-space: pre-wrap; } p.s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal { font-family: 'Times New Roman', 'serif'; font-size: 12pt; line-height: 108%; margin-top: 0; margin-left: 0; margin-right: 0; margin-bottom: .001pt; } span.s858a364f-81d7-412c-bfbc-eb87476b2fda000000 { font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } p.s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal-000001 { text-align: center; font-family: 'Times New Roman', 'serif'; font-size: 12pt; line-height: 108%; margin-top: 0; margin-left: 0; margin-right: 0; margin-bottom: .001pt; } span.s858a364f-81d7-412c-bfbc-eb87476b2fdaDefaultParagraphFont { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } 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p.s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal-000007 { text-align: right; font-family: 'Times New Roman', 'serif'; font-size: 12pt; line-height: 108%; margin-top: 0; margin-left: 0; margin-right: 0; margin-bottom: .001pt; } </style></head><body><div><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal"><span xml:space="preserve" class="s858a364f-81d7-412c-bfbc-eb87476b2fda000000"> </span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal"><span xml:space="preserve" class="s858a364f-81d7-412c-bfbc-eb87476b2fda000000"> </span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal"><span xml:space="preserve" class="s858a364f-81d7-412c-bfbc-eb87476b2fda000000"> </span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal"><span xml:space="preserve" class="s858a364f-81d7-412c-bfbc-eb87476b2fda000000"> </span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal"><span xml:space="preserve" class="s858a364f-81d7-412c-bfbc-eb87476b2fda000000"> </span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal"><span xml:space="preserve" class="s858a364f-81d7-412c-bfbc-eb87476b2fda000000"> </span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal"><span xml:space="preserve" class="s858a364f-81d7-412c-bfbc-eb87476b2fda000000"> </span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal"><span xml:space="preserve" class="s858a364f-81d7-412c-bfbc-eb87476b2fda000000"> </span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal"><span xml:space="preserve" class="s858a364f-81d7-412c-bfbc-eb87476b2fda000000"> </span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal"><span xml:space="preserve" class="s858a364f-81d7-412c-bfbc-eb87476b2fda000000"> </span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal"><span xml:space="preserve" class="s858a364f-81d7-412c-bfbc-eb87476b2fda000000"> </span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal"><span xml:space="preserve" class="s858a364f-81d7-412c-bfbc-eb87476b2fda000000"> </span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal-000001"><span class="s858a364f-81d7-412c-bfbc-eb87476b2fdaDefaultParagraphFont">DEPARTMENT OF LABOR AND REGULATION</span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal-000001"><span xml:space="preserve" class="s858a364f-81d7-412c-bfbc-eb87476b2fda000000"> </span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal-000001"><span class="s858a364f-81d7-412c-bfbc-eb87476b2fdaDefaultParagraphFont">DIVISION OF INSURANCE</span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal-000001"><span xml:space="preserve" class="s858a364f-81d7-412c-bfbc-eb87476b2fda000000"> </span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal-000001"><span xml:space="preserve" class="s858a364f-81d7-412c-bfbc-eb87476b2fda000000"> </span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal-000001"><span xml:space="preserve" class="s858a364f-81d7-412c-bfbc-eb87476b2fda000000"> </span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal-000001"><span xml:space="preserve" class="s858a364f-81d7-412c-bfbc-eb87476b2fda000000"> </span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal-000001"><span class="s858a364f-81d7-412c-bfbc-eb87476b2fdaDefaultParagraphFont">RESCISSION REPORTING FORM</span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal-000001"><span xml:space="preserve" class="s858a364f-81d7-412c-bfbc-eb87476b2fda000000"> </span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal-000001"><span xml:space="preserve" class="s858a364f-81d7-412c-bfbc-eb87476b2fda000000"> </span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal-000001"><span class="s858a364f-81d7-412c-bfbc-eb87476b2fdaDefaultParagraphFont">Chapter 20:</span><span class="s858a364f-81d7-412c-bfbc-eb87476b2fdaDefaultParagraphFont">06:21</span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal-000001"><span xml:space="preserve" class="s858a364f-81d7-412c-bfbc-eb87476b2fda000000"> </span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal-000001"><span class="s858a364f-81d7-412c-bfbc-eb87476b2fdaDefaultParagraphFont">APPENDIX D</span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal-000001"><span xml:space="preserve" class="s858a364f-81d7-412c-bfbc-eb87476b2fda000000"> </span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal-000001"><span class="s858a364f-81d7-412c-bfbc-eb87476b2fdaDefaultParagraphFont">SEE: §</span><span xml:space="preserve" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaDefaultParagraphFont-000002"> </span><span class="s858a364f-81d7-412c-bfbc-eb87476b2fdaDefaultParagraphFont">20:06:21:45</span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal-000001"><span xml:space="preserve" class="s858a364f-81d7-412c-bfbc-eb87476b2fda000000"> </span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal-000001"><span xml:space="preserve" class="s858a364f-81d7-412c-bfbc-eb87476b2fda000000"> </span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal-000001"><span xml:space="preserve" class="s858a364f-81d7-412c-bfbc-eb87476b2fda000000"> </span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal-000001"><span xml:space="preserve" class="s858a364f-81d7-412c-bfbc-eb87476b2fda000000"> </span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal-000001"><span xml:space="preserve" class="s858a364f-81d7-412c-bfbc-eb87476b2fda000000"> </span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal-000001"><span xml:space="preserve" class="s858a364f-81d7-412c-bfbc-eb87476b2fda000000"> </span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal-000001"><span xml:space="preserve" class="s858a364f-81d7-412c-bfbc-eb87476b2fda000000"> </span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal-000001"><span xml:space="preserve" class="s858a364f-81d7-412c-bfbc-eb87476b2fda000000"> </span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal-000001"><span xml:space="preserve" class="s858a364f-81d7-412c-bfbc-eb87476b2fda000000"> </span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal-000001"><span xml:space="preserve" class="s858a364f-81d7-412c-bfbc-eb87476b2fda000000"> </span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal-000001"><span xml:space="preserve" class="s858a364f-81d7-412c-bfbc-eb87476b2fda000000"> </span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal-000001"><span xml:space="preserve" class="s858a364f-81d7-412c-bfbc-eb87476b2fda000000"> </span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal-000001"><span xml:space="preserve" class="s858a364f-81d7-412c-bfbc-eb87476b2fda000000"> </span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal-000001"><span xml:space="preserve" class="s858a364f-81d7-412c-bfbc-eb87476b2fda000000"> </span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal-000001"><span xml:space="preserve" class="s858a364f-81d7-412c-bfbc-eb87476b2fda000000"> </span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal-000001"><span xml:space="preserve" class="s858a364f-81d7-412c-bfbc-eb87476b2fda000000"> </span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal-000001"><span xml:space="preserve" class="s858a364f-81d7-412c-bfbc-eb87476b2fda000000"> </span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal"><span xml:space="preserve" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaDefaultParagraphFont">    </span><span class="s858a364f-81d7-412c-bfbc-eb87476b2fdaDefaultParagraphFont-000003">Source:</span><span xml:space="preserve" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaDefaultParagraphFont"> 23 SDR 55, effective </span><span class="s858a364f-81d7-412c-bfbc-eb87476b2fdaDefaultParagraphFont">October 20, 1996.</span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal-000001"><span class="s858a364f-81d7-412c-bfbc-eb87476b2fdaDefaultParagraphFont-000004"><br />&#x200e;</span><span class="s858a364f-81d7-412c-bfbc-eb87476b2fdaDefaultParagraphFont">Model Regulation Service--April 1995</span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal-000001"><span xml:space="preserve" class="s858a364f-81d7-412c-bfbc-eb87476b2fda000000"> </span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal-000001"><span class="s858a364f-81d7-412c-bfbc-eb87476b2fdaDefaultParagraphFont">RESCISSION REPORTING FORM FOR</span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal-000001"><span class="s858a364f-81d7-412c-bfbc-eb87476b2fdaDefaultParagraphFont">LONG-TERM CARE POLICIES</span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal-000001"><span class="s858a364f-81d7-412c-bfbc-eb87476b2fdaDefaultParagraphFont">FOR THE STATE OF ______________</span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal-000001"><span class="s858a364f-81d7-412c-bfbc-eb87476b2fdaDefaultParagraphFont">FOR THE REPORTING YEAR 19____</span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal-000001"><span xml:space="preserve" class="s858a364f-81d7-412c-bfbc-eb87476b2fda000000"> </span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal-000001"><span xml:space="preserve" class="s858a364f-81d7-412c-bfbc-eb87476b2fda000000"> </span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal"><span class="s858a364f-81d7-412c-bfbc-eb87476b2fdaDefaultParagraphFont">Company Name: __________________________________________</span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal"><span xml:space="preserve" class="s858a364f-81d7-412c-bfbc-eb87476b2fda000000"> </span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal"><span class="s858a364f-81d7-412c-bfbc-eb87476b2fdaDefaultParagraphFont">Address:             __________________________________________</span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal"><span xml:space="preserve" class="s858a364f-81d7-412c-bfbc-eb87476b2fda000000"> </span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal"><span xml:space="preserve" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaDefaultParagraphFont">                 __________________________________________</span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal"><span xml:space="preserve" class="s858a364f-81d7-412c-bfbc-eb87476b2fda000000"> </span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal"><span class="s858a364f-81d7-412c-bfbc-eb87476b2fdaDefaultParagraphFont">Phone Number: ___________________________________________</span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal"><span xml:space="preserve" class="s858a364f-81d7-412c-bfbc-eb87476b2fda000000"> </span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal"><span xml:space="preserve" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaDefaultParagraphFont">                Due: March 1 annually</span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal"><span xml:space="preserve" class="s858a364f-81d7-412c-bfbc-eb87476b2fda000000"> </span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal"><span class="s858a364f-81d7-412c-bfbc-eb87476b2fdaDefaultParagraphFont-000003">Instructions:</span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal"><span xml:space="preserve" class="s858a364f-81d7-412c-bfbc-eb87476b2fda000000"> </span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal-000005"><span class="s858a364f-81d7-412c-bfbc-eb87476b2fdaDefaultParagraphFont">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></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal"><span xml:space="preserve" class="s858a364f-81d7-412c-bfbc-eb87476b2fda000000"> </span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal"><span xml:space="preserve" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaDefaultParagraphFont">                                                    Date of            Date/s</span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal"><span xml:space="preserve" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaDefaultParagraphFont">    Policy        Policy and            Name of        Policy            Claim/s    Date of</span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal"><span xml:space="preserve" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaDefaultParagraphFont-000006">    Form #        Certificate #        Insured            Issuance        Submitted    Rescission     </span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal"><span xml:space="preserve" class="s858a364f-81d7-412c-bfbc-eb87476b2fda000000"> </span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal"><span class="s858a364f-81d7-412c-bfbc-eb87476b2fdaDefaultParagraphFont">_______________________________________________________________________________</span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal"><span xml:space="preserve" class="s858a364f-81d7-412c-bfbc-eb87476b2fda000000"> </span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal"><span class="s858a364f-81d7-412c-bfbc-eb87476b2fdaDefaultParagraphFont">Detailed reason for rescission: ______________________________________________________</span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal"><span xml:space="preserve" class="s858a364f-81d7-412c-bfbc-eb87476b2fda000000"> </span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal"><span class="s858a364f-81d7-412c-bfbc-eb87476b2fdaDefaultParagraphFont">_______________________________________________________________________________</span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal"><span xml:space="preserve" class="s858a364f-81d7-412c-bfbc-eb87476b2fda000000"> </span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal"><span class="s858a364f-81d7-412c-bfbc-eb87476b2fdaDefaultParagraphFont">_______________________________________________________________________________</span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal"><span xml:space="preserve" class="s858a364f-81d7-412c-bfbc-eb87476b2fda000000"> </span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal"><span class="s858a364f-81d7-412c-bfbc-eb87476b2fdaDefaultParagraphFont">_______________________________________________________________________________</span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal"><span xml:space="preserve" class="s858a364f-81d7-412c-bfbc-eb87476b2fda000000"> </span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal"><span class="s858a364f-81d7-412c-bfbc-eb87476b2fdaDefaultParagraphFont">_______________________________________________________________________________</span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal"><span xml:space="preserve" class="s858a364f-81d7-412c-bfbc-eb87476b2fda000000"> </span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal-000007"><span class="s858a364f-81d7-412c-bfbc-eb87476b2fdaDefaultParagraphFont">_________________________________</span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal"><span xml:space="preserve" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaDefaultParagraphFont">                                                            Signature</span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal-000007"><span class="s858a364f-81d7-412c-bfbc-eb87476b2fdaDefaultParagraphFont">_________________________________</span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal"><span xml:space="preserve" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaDefaultParagraphFont">                                                            Name and Title (please type)</span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal-000007"><span class="s858a364f-81d7-412c-bfbc-eb87476b2fdaDefaultParagraphFont">_________________________________</span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal"><span xml:space="preserve" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaDefaultParagraphFont">                                                            Date</span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal"><span xml:space="preserve" class="s858a364f-81d7-412c-bfbc-eb87476b2fda000000"> </span></p><p dir="ltr" class="s858a364f-81d7-412c-bfbc-eb87476b2fdaNormal"><span class="s858a364f-81d7-412c-bfbc-eb87476b2fdaDefaultParagraphFont">Copyright NAIC 1995    641-31</span></p></div></body></html>