S.D. Admin. R. 20:06:21 app D
Model Regulation Service--April 1995
RESCISSION REPORTING FORM FOR
LONG-TERM CARE POLICIES
FOR THE STATE OF ______________
FOR THE REPORTING YEAR 19____
Company Name: __________________________________________
Address: __________________________________________
__________________________________________
Phone Number: ___________________________________________
Due: March 1 annually
Instructions:
The purpose of this form is to report all rescissions of long-term 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.
Date of Date/s
Policy Policy and Name of Policy Claim/s Date of
Form # Certificate # Insured Issuance Submitted Rescission
_______________________________________________________________________________
Detailed reason for rescission: ______________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_________________________________
Signature
_________________________________
Name and Title (please type)
_________________________________
Date
Copyright NAIC 1995 641-31
S.D. Admin. R. 20:06:21 app D