6.6.525    APPENDIX B - FORM FOR REPORTING MEDICARE SUPPLEMENT POLICIES

(1) This is the appendix referred to in ARM 6.6.521.

 

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                                                                           Date of

                               Certificate #                                                                        Issuance

 

 

 

 

 

 

 

_______________________________

                                                                                                                             Signature

 

_______________________________

                                                                                                                 Name and Title (please type)

 

_______________________________

                                                                                                                             Date

 

History: 33-22-904 and 33-22-905, MCA; IMP, 33-15-303, 33-22-901, 33-22-902, 33-22-903, 33-22-904, 33-22-905, 33-22-906, 33-22-907, 33-22-908, 33-22-909, 33-22-910, 33-22-911, 33-22-921, 33-22-922, 33-22-923, and 33-22-924, MCA; NEW, 2005 MAR p. 1672, Eff. 9/9/05.