Md. Code Regs. 31.14.01.29
Current through Register Vol. 51, No. 22, November 1, 2024
Reporting Form for Long-Term Care Policies. The following form is to be used for reporting rescissions made by each insurer as required by Regulation .09C of this chapter:
RESCISSION REPORTING FORM FOR LONG-TERM CARE POLICIES FOR THE STATE OFFOR 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 |
Md. Code Regs. 31.14.01.29