Wis. Admin. Code Office of the Commissioner of Insurance, ch. Ins 3, app 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

Notes

Wis. Admin. Code Office of the Commissioner of Insurance, ch. Ins 3, app 8