Ala. Admin. Code r. 482-1-071-AB
APPENDIX B
FORM FOR REPORTING
MEDICARE SUPPLEMENT POLICIES
Company Name: ______________________________
Address: ______________________________
______________________________
Phone Number: ______________________________
Due March 1, annually
The purpose of this form is to report the following information on each resident of this state who has in force more than one Medicare supplement policy or certificate. The information is to be grouped by individual policyholder.
| Policy and Certificate # | Date of Issuance |
___________________________________
Signature
___________________________________
Name and Title (please type)
___________________________________
Date
Author: Commissioner of Insurance
Statutory Authority: Code of Ala. 1975, §§27-2-17, 27-19-50 et seq.
History: Filed with LRS July 11, 2003. Rule is not subject to the Alabama Administrative Procedure Act. Revised: July 14, 2005; effective August 1, 2005. Rule is not subject to the Alabama Administrative Procedure Act. Revised: June 11, 2009; effective June 30, 2009. Filed with LRS June 12, 2009. Rule is not subject to the Alabama Administrative Procedure Act.