ARSD 20:06:21:0D – Rescission Reporting Form.

DEPARTMENT OF LABOR AND REGULATION

DIVISION OF INSURANCE

RESCISSION REPORTING FORM

Chapter 20:06:21

APPENDIX D

SEE: § 20:06:21:45

‎Model Regulation Service--April 1995

RESCISSION REPORTING FORM FOR

LONG-TERM CARE POLICIES

FOR THE STATE OF ______________

FOR THE REPORTING YEAR 19____

Company Name: __________________________________________

Address: __________________________________________

__________________________________________

Phone Number: ___________________________________________

Due: March 1 annually

Instructions:

The purpose of this form is to report all rescissions of long-term 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.

Date of Date/s

Policy Policy and Name of Policy Claim/s Date of

Form # Certificate # Insured Issuance Submitted Rescission

_______________________________________________________________________________

Detailed reason for rescission: ______________________________________________________

_______________________________________________________________________________

_________________________________

Signature

_________________________________

Name and Title (pleasetype)

_________________________________

Date

Source: 23 SDR 55, effective October 20, 1996.