N.H. Admin. Code Ins, ch. Ins 1900, pt. Ins 1905, app B
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
N.H. Admin. Code Ins, ch. Ins 1900, pt. Ins 1905, app B
The amended version of this appendix by New Hampshire Register Volume 37, Number 37, eff. 10/13/2017 is not yet available.