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PDFWAC 284-83-165

Form for reporting rescission of long-term care policies.

The following form must be used by issuers to annually report rescission of long-term care policies.
RESCISSION REPORTING FORM FOR LONG-TERM CARE POLICIES FOR THE STATE
OF        FOR THE REPORTING YEAR 20[ ]
Company Name:                         
Address:                              
                                      
Phone Number:                         
Due: March 1, annually
Instructions: The purpose of this form is to report all rescissions of long-term care insurance policies or certificates. Those rescissions voluntarily effectuated by an insured are not required to be included in this report. Please furnish one form per rescission.
Policy Form #
Policy and
Certificate #
Name of
Insured
Date of Policy Issuance
Date/s Claim/s Submitted
Date of
Rescission
Detailed reason for rescission:                
                                               
                                               
                                               
                                               
                                     
Signature
                                     
Name and Title (please type)
                                     
Date
[Statutory Authority: RCW 48.02.060, 48.83.070, 48.83.110, 48.83.120, 48.83.130(1), and 48.83.140 (4)(a). WSR 08-24-019 (Matter No. R 2008-09), § 284-83-165, filed 11/24/08, effective 12/25/08.]
Reviser's note: The brackets and enclosed material in the text of the above section occurred in the copy filed by the agency.
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