S.C. Code Regs. § ch. 69, 69-44, app 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 Policy and Name of Date of Date/s Date of
Form # Certificate Insured Policy Claim/s Rescission
# Issuance Submitted
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Detailed reason for rescission:___ ___ ___ ___
__________
Signature
__________
Name and Title (please type)
__________
Date
S.C. Code Regs. ch. 69, 69-44, app A