N.H. Admin. Code Ins, ch. Ins 3600, pt. Ins 3601, app A
RESCISSION REPORTING FORM FOR
LONG-TERM CARE POLICIES
FOR THE STATE OF _____________
FOR 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.
Date of Date/s
Policy Policy and Name of Policy Claim/s Date of
Form # Certificate # Insured Issuance Submitted Rescission
Detailed reason for rescission:________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
____________________________________
Signature
____________________________________
Name and Title (please type)
____________________________________
Date
N.H. Admin. Code Ins, ch. Ins 3600, pt. Ins 3601, app A
The amended version of this appendix by New Hampshire Register Volume 35, Number 10, eff.2/13/2015 is not yet available.