23 CAR pt. 84, Appendix A. Rescission Reporting Form for Long-Term Care Policies

APPENDIX A RESCISSION REPORTING FORM FOR LONG-TERM CARE POLICIES FOR THE STATE OF _______________ FOR THE REPORTING YEAR 20[ ] Company Name: ________________________________________________________________ Address: ________________________________________________________________ ________________________________________________________________ Phone Number: _______________________________________________________________________ Due: March 1 annually Instructions: The purpose of this form is to report all rescissions 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 rescission. Policy Form # Policy and Certificate # Name of Insured Date of Policy Issuance Date/s Claim/s Submitted Date of Rescission Detailed reason for rescission: ___________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ __________________________________ Signature __________________________________ Name and Title (please type) __________________________________ Date