South Carolina Code of Regulations
Chapter 69 - DEPARTMENT OF INSURANCE
69-46 APPENDIX B - FORM FOR REPORTING

Universal Citation: SC Code Regs 69-46 APPENDIX B

APPENDIX 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.

Policy andDate of
Certificate #Issuance

______________

Signature

______________

Name and Title (please type)

Date

HISTORY: Added by State Register Volume 13, Issue 1, adopted Jan. 27, 1989, eff July 1, 1989. Amended by State Register Volume 14, Issue 6, eff June 22, 1992; State Register Volume 14, Issue 6, eff June 22, 1990; State Register Volume 15, Issue 12, adopted Dec. 27, 1991, eff May 1, 1992; State Register Volume 20, Issue No. 4, eff April 28, 1; State Register Volume 23, Issue No. 3, eff March 26, 1999; State Register Volume 27, Issue No. 10, eff October 24, 2003; State Register Volume 29, Issue No. 7, eff July 22, 2005; State Register Volume 33, Issue No. 5, eff May 22, 2009; SCSR 42-1 Doc. No. 4804, eff January 26, 2018.

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