LAC 37:XIII.597
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
AUTHORITY NOTE: Promulgated in accordance with R.S. 22:224 and 42 U.S.C. 1395 et seq.
HISTORICAL NOTE: Promulgated by the Department of Insurance, Office of the Commissioner, LR 25:1136 (June 1999), repromulgated LR 25:1516 (August 1999), LR 29:2482 (November 2003), LR 31:2943 (November 2005).