Illinois Administrative Code
Title 50 - INSURANCE
Part 2012 - LONG-TERM CARE INSURANCE
Exhibit D - Rescission Reporting Format
RESCISSION REPORTING FORMS FOR LONG-TERM CARE POLICIES FOR THE STATE OF ILLINOIS FOR 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:
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
_____________________________
Signature
_____________________________
Name and Title (please type)
_____________________________
Date
