Sec. 31.14.01.29. Rescission

Reporting Form for Long-Term Care Policies. The following form is to be used for reporting rescissions made by each insurer as required by Regulation .09C of this chapter:

RESCISSION REPORTING FORM FOR LONG-TERM CARE POLICIES FOR THE STATE OFFOR 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 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

Detailed reason for rescission: _______________________________

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Signature

___________________________
Name and Title (please type)

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Date