New Hampshire Code of Administrative Rules
Ins - Commissioner, Insurance Department
Chapter Ins 3600 - LONG-TERM CARE INSURANCE
Part Ins 3601 - 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.

Date of Date/s

Policy Policy and Name of Policy Claim/s Date of

Form # Certificate # Insured Issuance Submitted Rescission

Detailed reason for rescission:________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

____________________________________

Signature

____________________________________

Name and Title (please type)

____________________________________

Date

The amended version of this appendix by New Hampshire Register Volume 35, Number 10, eff.2/13/2015 is not yet available.