WAC 284-66-323. Form for reporting multiple medicare supplement policies and certificates

Medicare Supplement Regulation form for reporting medicare supplement policies Company Name: Address: Phone Number: Due: March 1, annually 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 with more than one medicare supplement policy or certificate in force. The information is to be grouped by individual policyholder. Policy and Certificate # Date of Issuance Policy and Certificate # Date of Issuance Signature Name and Title (please type) Date Signature Name and Title (please type) Date