LAC 37:XIII.597. Appendix B—Medicare Supplement Policies Reporting Form

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 Certificate # | Date of Issuance ________________________________________ Signature ________________________________________ Name and Title (please type) ________________________________________ Date