La. Admin. Code tit. 37 § XIII-597

Current through Register Vol. 50, No. 6, June 20, 2024

Section XIII-597 - Appendix B-Medicare Supplement Policies Reporting Form

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 Certificate #

Date of Issuance

________________________________________

Signature

________________________________________

Name and Title (please type)

________________________________________

Date

La. Admin. Code tit. 37, § XIII-597

Promulgated by the Department of Insurance, Office of the Commissioner, LR 25:1136 (June 1999), repromulgated LR 25:1516 (August 1999), LR 29:2482 (November 2003), LR 31:2943 (November 2005).

AUTHORITY NOTE: Promulgated in accordance with R.S. 22:224 and 42 U.S.C. 1395 et seq.