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WAC 284-66-323

Agency filings affecting this section

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.]