WAC 284-66-323:

WACs > Title 284 > Chapter 284-66 > Section 284-66-323

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284-66-320 << 284-66-323 >> 284-66-330

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PDFWAC 284-66-323

Form for reporting multiple medicare supplement policies and certificates.

Medicare Supplement Regulation

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 with more than one medicare supplement policy or certificate in force. The information is to be grouped by individual policyholder.

Policy and

Certificate #

Date of

Issuance


	Signature

	Name and Title (please type)

	Date

[Statutory Authority: RCW 48.66.030 (3)(a), 48.66.041, and 48.66.165. WSR 09-24-052 (Matter No. R 2009-08), § 284-66-323, filed 11/24/09, effective 1/19/10. Statutory Authority: RCW 48.02.060, 48.20.450, 48.20.460, 48.20.470, 48.30.010, 48.44.020, 48.44.050, 48.44.070, 48.46.030, 48.46.130 and 48.46.200. WSR 92-06-021 (Order R 92-1), § 284-66-323, filed 2/25/92, effective 3/27/92.]