Sec. 31.10.06.20. Form for Reporting Multiple Policies

The following form is to be used in making reports of multiple policies in accordance with the requirements of Regulation .17 of this chapter:

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