Wash. Admin. Code § 284-66-323
Medicare Supplement Regulation
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 with more than one medicare supplement policy or certificate in force. The information is to be grouped by individual policyholder.
| Policy andCertificate # | Date ofIssuance |
| Signature | |
| Name and Title (please type) | |
| Date |
[Statutory Authority: RCW 48.66.030 (3)(a), 48.66.041, and 48.66.165. WSR 09-24-052 (Matter No. R 2009-08), § 284-66-323, filed 11/24/09, effective 1/19/10. Statutory Authority: RCW 48.02.060, 48.20.450, 48.20.460, 48.20.470, 48.30.010, 48.44.020, 48.44.050, 48.44.070, 48.46.030, 48.46.130 and 48.46.200. WSR 92-06-021 (Order R 92-1), § 284-66-323, filed 2/25/92, effective 3/27/92.]