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Virginia Administrative Code (Last Updated: January 10, 2017) |
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Title 14. Insurance |
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Agency 5. State Corporation Commission, Bureau of Insurance |
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Chapter 170. Rules Governing Minimum Standards for Medicare Supplement Policies |
Section 220:2. APPENDIX B. FORM FOR REPORTING MEDICARE SUPPLEMENT POLICIES
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APPENDIX B
8/05
APPENDIX B
FORM FOR REPORTING MEDICARE SUPPLEMENT POLICIESCompany Name:_____________________________
Address:___________________________________
__________________________________________
Phone Number: ______________________________
Due March 1, annually
The purpose of this form is to report the following information on each resident of Virginia who has in force more than one Medicare supplement policy or certificate. The information is to be grouped by individual policyholder.
Policy and Certificate #
Date of Issuance
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
___________________________________________
Signature
___________________________________________
Name and Title (please type)
___________________________________________
Date
Historical Notes
Derived from Regulation 35, Case No. INS920112, § 19, eff. July 30, 1992; amended, Volume 21, Issue 25, eff. August 15, 2005.