Wis. Admin. Code Office of the Commissioner of InsuranceIns 3.39 app 9

Current through November 29, 2021

FORM FOR REPORTING MEDICARE SUPPLEMENT POLICIES

Company Name: __________________________________________________________________________________________

Address:_________________________________________________________________________________ ___________________________________________________________________________________________

Phone Number:__________________________

Due March 1, annually

The purpose of this form is to report the following information on each resident of this state who has in force more than one Medicare supplement policy or certificate. The information is to be grouped by individual policyholder.

Policy and Certificate Number

Date of Issuance

___________________________________________________

Signature

___________________________________________________

Name and Title (please type)

___________________________________________________

Date

Notes

Wis. Admin. Code Office of the Commissioner of InsuranceIns 3.39 app 9

The following state regulations pages link to this page.



State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.