50 Ill. Adm. Code 2012.EXHIBIT D
D Rescission Reporting Format
Section 2012
Section 2012.EXHIBIT D Rescission
Reporting Format
RESCISSION
REPORTING FORMS FOR
LONG-TERM
CARE POLICIES
FOR
THE STATE OF ILLINOIS
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