North Dakota Administrative Code
Title 45 - Insurance, Commissioner of
Article 45-06 - Accident and Health Insurance
Chapter 45-06-05 - Long-Term Care Insurance Model Regulation
Appendix A
RECISSION REPORTING FORM FOR
LONG-TERM CARE POLICIES
FOR THE STATE OF __________________________
FOR THE REPORTING YEAR 20[ ]
Company Name:_____________________________
Address:___________________________________
____________________________________
Telephone 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 recissions voluntarily effectuated by an insured are not required to be included in this report. Please furnish one form per rescission.
| Policy Form Number | Policy and Certificate # | Name of Insured | Date of Policy Issuance | Date/s Claim/s Submitted | Date of Rescission |
_____________________________________________________
Date of Rescission: ______________________________
______________________________________________
______________________________________________
______________________________________________
______________________________________________
__________________________
Signature
__________________________
Name and Title (please type)
__________________________
Date
