14VAC5-170-220:2: APPENDIX B. FORM FOR REPORTING MEDICARE SUPPLEMENT POLICIES

APPENDIX B

8/05

APPENDIX B

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 Virginia 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