23 CAR pt. 89, Appendix B. Form for Reporting Medicare Supplement Policies

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 this state who has in force more than one Medicare supplement policy or certificate. The information is to be grouped by individual policyholder. Policy and Date of Certificate # Issuance Signature Name and Title (please type) Date