RESCISSION REPORTING FORM FOR LONG-TERM CARE POLICIES FOR THE STATE OF NEW MEXICO FOR THE REPORTING YEAR [ ] 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 Number 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

RESCISSION REPORTING FORM FOR LONG-TERM CARE POLICIES FOR THE STATE OF NEW MEXICO FOR THE REPORTING YEAR [ ]

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 Number Name of Insured Date of Policy Issuance Date(s) Claim(s) Submitted Date of Rescission

Policy Form

Policy and

Certificate Number

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

[1-1-99; 13.10.15.49 NMAC - Rn, 13 NMAC 10.15.46, 1-1-04]