14 Va. Admin. Code § 5-170-220:2

Current through Register Vol. 40, No. 22, June 17, 2024

Section 14VAC5-170-220:2 - APPENDIX B. FORM FOR REPORTING MEDICARE SUPPLEMENT POLICIES

8/05

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 Virginia who has in force 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

14 Va. Admin. Code § 5-170-220:2

Derived from Regulation 35, Case No. INS920112, § 19, eff. July 30, 1992; amended, Virginia Register Volume 21, Issue 25, eff. August 15, 2005.

Statutory Authority

§§ 12.1-13 and 38.2-223 of the Code of Virginia.