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054.00.13 Appendix A. Recission Reporting Form for Long-Term Care Policies.

AR ADC 054.00.13 Appendix AArkansas Administrative Code

West's Arkansas Administrative Code
Title 054. Insurance Department
Division 00.
Rule 13. Long Term Care Insurance
Ark. Admin. Code 054.00.13 Appendix A
054.00.13 Appendix A. Recission Reporting Form for Long-Term Care Policies.
Currentness
RESCISSION REPORTING FORM FOR LONG-TERM CARE POLICIES FOR THE STATE OF __________ 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
Current with amendments received through May 15, 2024. Some sections may be more current, see credit for details.
Ark. Admin. Code 054.00.13 Appendix A, AR ADC 054.00.13 Appendix A
End of Document