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054.00.27 APPENDIX B. FORM FOR REPORTING MEDICARE SUPPLEMENT POLICIES

AR ADC 054.00.27 APPENDIX BArkansas Administrative CodeEffective: February 1, 2018

West's Arkansas Administrative Code
Title 054. Insurance Department
Division 00.
Rule 27. Minimum Standards for Medicare Supplement Policies
Effective: February 1, 2018
Ark. Admin. Code 054.00.27 APPENDIX B
054.00.27 APPENDIX B. FORM FOR REPORTING MEDICARE SUPPLEMENT POLICIES
Currentness
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 Certificate #
Date of Issuance
________________________________________
Signature
________________________________________
Name and Title (please type)
____________________
Date

Credits

Amended July 1, 2009; Feb. 1, 2018.
Current with amendments received through May 15, 2024. Some sections may be more current, see credit for details.
Ark. Admin. Code 054.00.27 APPENDIX B, AR ADC 054.00.27 APPENDIX B
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