Mont. Admin. R. 6.6.525

Current through Register Vol. 11, June 7, 2024

Rule 6.6.525 - APPENDIX B - FORM FOR REPORTING MEDICARE SUPPLEMENT POLICIES

(1) This is the appendix referred to in ARM 6.6.521.

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 Date of

Certificate # Issuance

_______________________________

Signature

_______________________________

Name and Title (please type)

_______________________________

Date

Mont. Admin. R. 6.6.525

NEW, 2005 MAR p. 1672, Eff. 9/9/05.

33-22-904 and 33-22-905, MCA; IMP, 33-15-303, 33-22-901, 33-22-902, 33-22-903, 33-22-904, 33-22-905, 33-22-906, 33-22-907, 33-22-908, 33-22-909, 33-22-910, 33-22-911, 33-22-921, 33-22-922, 33-22-923, and 33-22-924, MCA;