Ill. Admin. Code tit. 50, pt. 2008, subpt. G, app U

Current through Register Vol. 48, No. 43, October 25, 2024

Appendix U - Medicare Supplement Policies Report

Company Name: _______________________________________________________

Address: _____________________________________________________________

Phone Number: ________________________________________________________

Due: March 1, annually

The purpose of this report is to provide information on each resident of this State who has 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

Ill. Admin. Code tit. 50, pt. 2008, subpt. G, app U

Appendix U renumbered from Appendix P at 29 Ill. Reg. 14188, effective September 8, 2005