Neb. Admin. Code INSURANCE, DEPARTMENT OF, tit. 210, ch. 46, app A

Current through September 17, 2024

Appendix A - 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 Claims/s Submitted	Date of Rescission

Detailed reason for rescission:

____________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

___________________________

Signature

___________________________

Name and Title (please type)

___________________________

Date

Neb. Admin. Code INSURANCE, DEPARTMENT OF, tit. 210, ch. 46, app A