Wis. Admin. Code Office of the Commissioner of Insurance, ch. Ins 3, app 8
RESCISSION REPORTING FORM FOR LONG-TERM CARE POLICIES
FOR THE STATE OF _______________
FOR THE REPORTING YEAR [ ]
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)
__________________________________
Date
Wis. Admin. Code Office of the Commissioner of Insurance, ch. Ins 3, app 8