Rule 20:06:13:0B Form for Reporting Medicare Supplement Policies.
DEPARTMENT OF REVENUE AND REGULATION
OF LABOR AND REGULATION
Source: 18 SDR 225, effective July 17, 1992;
39 SDR 10, effective August 1, 2012.
FORM FOR REPORTING
MEDICARE SUPPLEMENT POLICIES
Company Name: ______________________________
Phone Number: ______________________________
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.
and Date of
and Title (please type)
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