S.D. Admin. R. 20:06:13 app B
Current through Register Vol. 50, page 159, June 17, 2024
APPENDIX B
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 in force more than one Medicare supplement policy or certificate. The information is to be grouped by individual policyholder.
Policy and Date of
Certificate # Issuance
___________________________________
Signature
___________________________________
Name and Title (please type)
___________________________________
Date
S.D. Admin. R. 20:06:13 app B