Wash. Admin. Code § 284-83-165
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
Wash. Admin. Code § 284-83-165
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). 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.