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