Code of Maine Rules
02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION
031 - BUREAU OF INSURANCE
Chapter 275 - Medicare Supplement Insurance
Appendix 031-275-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.

___________________________________

Signature

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Name and Title (please type)

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Date