{"data":{"id":"us-va/14vac5-170-220-2","jurisdiction":"us-va","citation":"14VAC5-170-220:2","heading":"APPENDIX B. FORM FOR REPORTING MEDICARE SUPPLEMENT POLICIES","body":"APPENDIX B\n\n8/05\n\nAPPENDIX B\n\nFORM FOR REPORTING MEDICARE SUPPLEMENT POLICIES\n\nCompany Name:_____________________________\n\nAddress:___________________________________\n\n__________________________________________\n\nPhone Number: ______________________________\n\nDue March 1, annually\n\nThe 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.\n\nPolicy and Certificate #\n\nDate of Issuance\n\n__________________________________________________________________________________________\n\n__________________________________________________________________________________________\n\n__________________________________________________________________________________________\n\n__________________________________________________________________________________________\n\n__________________________________________________________________________________________\n\n___________________________________________\n\nSignature\n\n___________________________________________\n\nName and Title (please type)\n\n___________________________________________\n\nDate","path":["Title 14. Insurance","Agency 5. State Corporation Commission, Bureau of Insurance","Chapter 170. Rules Governing Minimum Standards for Medicare Supplement Policies"],"source_url":"https://law.lis.virginia.gov/admincode/title14/agency5/chapter170/section220:2/","current_through":"2026 Regular Session (effective July 1, 2026)","vintage":"","retrieved_at":"2026-09-14T04:51:53Z","sha256":"bfaa7e40aaf891efcd308a475d70d12576fe6a8ecd8caa1a3062cb2dff561abd","source_id":"us-va-vac","stale":false,"prev":"us-va/14vac5-170-220-1","next":"us-va/14vac5-170-220-3"},"notice":"GroundRules: Original legal text. Not legal advice."}