Delaware Administrative Code
Title 18 - Insurance
1500 - Medicare Supplement Policies
1501 - Medicare Supplement Insurance Minimum Standards
Appendix B - 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 Date of

Certificate # Issuance

___________________________________

Signature

___________________________________

Name and Title (please type)

___________________________________

Date