Wyoming Administrative Code
Agency 044 - Insurance Dept
Sub-Agency 0002 - General Agency, Board or Commission Rules
Chapter 37 - LONG-TERM CARE REGULATION
Appendix A

RECISSION REPORTING FORM FOR

LONG-TERM CARE POLICIES

FOR THE STATE OF WYOMING

FOR THE REPORTING YEAR 20[ ]

Company Name:________________________________________

Address:______________________________________________

_____________________________________________________

Phone Number:_________________________________________

Due: March 1 annually

Instructions:

The purpose of this form is to report all recissions 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 recission.

Date of Policy Date/s

Policy Policy and Name of Issuance Claim/s Date of

Form # Certificate # Insured Submitted Rescission

Detailed reason for rescission:____________________________

____________________________________________________

____________________________________________________

____________________________________________________

____________________

Signature

_____________________

Name and Title (please type)

______________________

Date