Pa. Code tit. 31, pt. IV, ch. 89, subch. M, app F

Current through Register Vol. 54, No. 44, November 2, 2024

Appendix F

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 inforce more than one Medicare supplement policy or certificate. The information is to be grouped by individual policyholder.

Policy and Certificate #

Date of Issuance

______________________________________

Signature

______________________________________

Name and Title (please type)

______________________________________

Date

Pa. Code tit. 31, pt. IV, ch. 89, subch. M, app F

The provisions of this Appendix F adopted July 24, 1992, effective 7/25/1992, 22 Pa.B. 3841.