South Carolina Code of Regulations
Chapter 69 - DEPARTMENT OF INSURANCE
69-44 APPENDIX A - RESCISSION REPORTING

Universal Citation: SC Code Regs 69-44 APPENDIX A

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

HISTORY: Added by State Register Volume 13, Issue No. 6, effective 180 days after June 23, 1989. Amended by State Register Volume 34, Issue No. 5, eff May 28, 2010.

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