Pa. Code tit. 31, pt. IV, ch. 89a, app A - RESCISSION REPORTING FORM FOR LONG-TERM CARE POLICIES FOR THE STATE OF 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

Pa. Code tit. 31, pt. IV, ch. 89a, app A

This appendix cited in 31 Pa. Code § 89a.110 (relating to prohibition against postclaims underwriting).