Wisconsin Administrative Code
Office of the Commissioner of Insurance
Chapter Ins 3 - Casualty Insurance
Appendix 8
RESCISSION REPORTING FORM FOR LONG-TERM CARE POLICIES
FOR THE STATE OF _______________
FOR THE REPORTING YEAR [ ]
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: ____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
__________________________________
Signature
__________________________________
Name and Title (please type)
__________________________________
Date
