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