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: __________________________________________________________________________________________
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
Name and Title (please type)
The following state regulations pages link to this page.
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