Ill. Admin. Code tit. 50, pt. 2012, exh. D
RESCISSION REPORTING FORMS FOR LONG-TERM CARE POLICIES FOR THE STATE OF ILLINOIS FOR THE REPORTING YEAR 20[ ]
Company Name: ________________________________________________
Address: ______________________________________________________
____________________________________________________________
Phone Number: __________________________________________________
Due: March 1 annually
Instructions:
The purpose of this form is to report all rescissions of long-term care 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.
Policy Form # | Policy and Certificate # | Name of Insured | Date of Policy Issuance | Date/s Claim/s Submitted | Date of Rescission |
Detailed reason for rescission:
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
_____________________________
Signature
_____________________________
Name and Title (please type)
_____________________________
Date
Ill. Admin. Code tit. 50, pt. 2012, exh. D