Nebraska Administrative Code
Topic - INSURANCE, DEPARTMENT OF
Title 210 - NEBRASKA DEPARTMENT OF INSURANCE
Chapter 46 - LONG-TERM CARE INSURANCE
Appendix A - RESCISSION REPORTING FORM FOR LONG-TERM CARE POLICIES
FOR THE STATE OF ___________________
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 Claims/s Submitted | Date of Rescission |
Detailed reason for rescission:
____________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
___________________________
Signature
___________________________
Name and Title (please type)
___________________________
Date
