WAC 284-55-080. Form for "replacement notice."

notice to applicant regarding replacement of accident and sickness insurance According to (your application) (information you have furnished), you intend to lapse or otherwise terminate existing accident and sickness insurance and replace it with a policy to be issued by (company name) insurance company. Federal and state law provides thirty days within which you may decide without cost whether you desire to keep the policy. For your own information and protection, you should be aware of and seriously consider certain factors which may affect the insurance protection available to you under the new policy. Drafting note. This subsection may be modified if preexisting conditions are covered under the new policy. The above "Notice to Applicant" was delivered to me on: . . . . (Date) . . . . (Applicant’s Signature) . . . . (Date) . . . . (Applicant’s Signature)