Louisiana Administrative Code
Title 37 - INSURANCE Part
Part XIII - Regulations
Chapter 5 - Regulation 33-Medicare Supplement Insurance Minimum Standards
Section XIII-597 - Appendix B-Medicare Supplement Policies Reporting Form
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 # |
Date of Issuance |
________________________________________
Signature
________________________________________
Name and Title (please type)
________________________________________
Date
AUTHORITY NOTE: Promulgated in accordance with R.S. 22:224 and 42 U.S.C. 1395 et seq.
