Appendix A -
RECISSION REPORTING FORM FOR
LONG-TERM CARE POLICIES
FOR THE STATE OF WYOMING
FOR THE REPORTING YEAR 20[ ]
Company Name:________________________________________
Address:______________________________________________
_____________________________________________________
Phone Number:_________________________________________
Due: March 1 annually
Instructions:
The purpose of this form is to report all recissions of long-term care 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 recission.
Date of Policy Date/s
Policy Policy and Name of Issuance Claim/s Date of
Form # Certificate # Insured Submitted Rescission
Detailed reason for rescission:____________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________
Signature
_____________________
Name and Title (please type)
______________________
Date