Exhibit D - Rescission Reporting Format

Current through Register Vol. 46, No. 15, April 8, 2022

RESCISSION REPORTING FORMS FOR LONG-TERM CARE POLICIES FOR THE STATE OF ILLINOIS 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:

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

_____________________________

Signature

_____________________________

Name and Title (please type)

_____________________________

Date

Notes

Amended at 32 Ill. Reg. 7600, effective May 5, 2008

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