Wis. Admin. Code Office of the Commissioner of Insurance, ch. Ins 3, app 9
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 Number | Date of Issuance |
___________________________________________________
Signature
___________________________________________________
Name and Title (please type)
___________________________________________________
Date
Wis. Admin. Code Office of the Commissioner of Insurance, ch. Ins 3, app 9