Medicare Supplement Regulation
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 this state with more than one medicare supplement policy or certificate in force. The information is to be grouped by individual policyholder.
Policy and Certificate # | Date of Issuance |
| |
| Signature |
| |
| Name and Title (please type) |
| |
| Date |
[Statutory Authority: RCW
48.66.030 (3)(a),
48.66.041, and
48.66.165. WSR 09-24-052 (Matter No. R 2009-08), § 284-66-323, filed 11/24/09, effective 1/19/10. Statutory Authority: RCW
48.02.060,
48.20.450,
48.20.460,
48.20.470,
48.30.010,
48.44.020,
48.44.050,
48.44.070,
48.46.030,
48.46.130 and
48.46.200. WSR 92-06-021 (Order R 92-1), § 284-66-323, filed 2/25/92, effective 3/27/92.]