Section 2012

Section 2012.EXHIBIT D Rescission Reporting Format

RESCISSION REPORTING FORMS FOR

LONG-TERM CARE POLICIES

FOR THE STATE OF ILLINOIS

FOR THE REPORTING YEAR 20[ ]

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 #

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

(Source: Amended at 32 Ill. Reg. 7600, effective May 5, 2008)