N.D. Admin. Code app A

Current through Supplement No. 393, July, 2024

Appendix A

RECISSION REPORTING FORM FOR

LONG-TERM CARE POLICIES

FOR THE STATE OF __________________________

FOR THE REPORTING YEAR 20[ ]

Company Name:_____________________________

Address:___________________________________

____________________________________

Telephone 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 recissions voluntarily effectuated by an insured are not required to be included in this report. Please furnish one form per rescission.

Policy Form Number

Policy and Certificate #

Name of Insured

Date of Policy Issuance

Date/s Claim/s Submitted

Date of Rescission

_____________________________________________________

Date of Rescission: ______________________________

______________________________________________

______________________________________________

______________________________________________

______________________________________________

__________________________

Signature

__________________________

Name and Title (please type)

__________________________

Date

N.D. Admin Code app A