WAC 284-212-165. Form for reporting rescission of supplemental long-term care insurance policies

The following form must be used by issuers to annually report rescission of supplemental long-term care insurance policies. RESCISSION REPORTING FORM FOR SUPPLEMENTAL LONG-TERM CARE INSURANCE POLICIES FOR THE STATE OF 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 supplemental 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 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