ARM 6.6.525. APPENDIX B - FORM FOR REPORTING MEDICARE SUPPLEMENT POLICIES

(1) This is the appendix referred to in ARM 6.6.521. 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