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