N.D. Admin. Code app A
RESCISSION 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 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 # | Name of Insured | Date of Policy Issuance | Date/s Claim/s Submitted | Date of Rescission |
Detailed reason for rescission:__________________________
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Signature
____________________________
Name and title (please type)
____________________________
Date
N.D. Admin Code app A