U Medicare Supplement Policies Report

Section 2008.APPENDIX U   Medicare Supplement Policies Report Company Name: Address: Phone Number: Due:  March 1, annually The purpose of this report is to provide information on each resident of this State who has 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