Ill. Admin. Code tit. 50, § 2012.EXHIBIT D – Rescission Reporting Format

RESCISSION REPORTING FORMS FOR

LONG-TERM CARE POLICIES

FOR THE STATE OF ILLINOIS

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

(Source: Amended at 32 Ill. Reg. 7600, effective May 5, 2008)