DEPARTMENT OF LABOR AND REGULATION

DIVISION OF INSURANCE

FORM FOR REPORTING

MEDICARE SUPPLEMENT POLICIES

Chapter 20:06:13

APPENDIX B

SEE: § 20:06:13:53

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 Date of

Certificate # Issuance

___________________________________

Signature

___________________________________

Name and Title (pleasetype)

___________________________________

Date

Source: 18 SDR 225, effective July 17, 1992; 39 SDR 10, effective August 1, 2012.