West Virginia Code of State Rules
Agency 114 - Insurance Commission
Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER
Series 114-32 - Long-Term Care Insurance
Appendix A
RESCISSION REPORTING FORM FOR
LONG-TERM CARE POLICIES
FOR THE STATE OF WEST VIRGINIA
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 Form # | Policy and Certificate # | Name of Insured | Date of Policy Issuance | Date/s Claim/s Submitted | Date of Rescission |
Detailed reason for rescission: _____________________
_____________________________________________
_____________________________________________
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________________
Signature
________________
Name and Title (please type)
________________
Date
