South Carolina Code of Regulations
Chapter 69 - DEPARTMENT OF INSURANCE
Subchapter 69-44 - 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 Policy and Name of Date of Date/s Date of

Form # Certificate Insured Policy Claim/s Rescission

# Issuance Submitted

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Detailed reason for rescission:___ ___ ___ ___

__________

Signature

__________

Name and Title (please type)

__________

Date