(1) This is the appendix referred to in ARM 6.6.521.
FORM FOR REPORTING MEDICARE SUPPLEMENT POLICIES
Company Name: ____________________________
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
Name and Title (please type)