Statutes, codes, and regulations
Washington Administrative Code
Title 284 - Insurance Commissioner, Office of the
Chapter 284-66 - Washington medicare supplement insurance regulation
Section 284-66-323 - Form for reporting multiple medicare supplement policies and certificates

Wash. Admin. Code § 284-66-323

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Current through Register Vol. 24-23, December 1, 2024
Section 284-66-323 - Form for reporting multiple medicare supplement policies and certificates

Medicare Supplement Regulation

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 with more than one medicare supplement policy or certificate in force. The information is to be grouped by individual policyholder.

Policy and

Certificate #

Date of

Issuance

Signature

Name and Title (please type)

Date

Wash. Admin. Code § 284-66-323

Statutory Authority: RCW 48.66.030(3)(a), 48.66.041, and 48.66.165. 09-24-052 (Matter No. R 2009-08), § 284-66-323, filed 11/24/09, effective 1/19/10. Statutory Authority: RCW 48.02.060, 48.20.450, 48.20.460, 48.20.470, 48.30.010, 48.44.020, 48.44.050, 48.44.070, 48.46.030, 48.46.130 and 48.46.200. 92-06-021 (Order R 92-1), § 284-66-323, filed 2/25/92, effective 3/27/92.