N.M. Admin. Code § 13.10.15.49
RESCISSION REPORTING FORM FOR LONG-TERM CARE POLICIES FOR THE STATE OF NEW MEXICO FOR THE REPORTING YEAR [ ]
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 Number | 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
N.M. Admin. Code § 13.10.15.49