The following form must be used by issuers to annually report rescission of long-term care policies.
RESCISSION REPORTING FORM FOR LONG-TERM CARE POLICIES FOR THE STATE
OF FOR THE REPORTING YEAR 20[ ]
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 #
Date of Policy Issuance
Date/s Claim/s Submitted
Detailed reason for rescission:
Name and Title (please type)