Del. Admin. Code tit. 18, 1400, 1404, app A
RESCISSION REPORTING FORM FOR
LONG-TERM CARE POLICIES
FOR THE STATE OF DELAWARE
FOR THE REPORTING YEAR 19[ ]
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
Del. Admin. Code tit. 18, 1400, 1404, app A