Md. Code Regs. 31.10.06.20
Current through Register Vol. 51, No. 22, November 1, 2024
The following form is to be used in making reports of multiple policies in accordance with the requirements of Regulation .17 of this chapter:
FORM FOR REPORTINGMEDICARE 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 |
Md. Code Regs. 31.10.06.20