Appendix F.

FORM FOR REPORTING MEDICARE SUPPLEMENT POLICIES
Company Name:

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Address:

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Phone Number:

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Due: March 1, annually

The purpose of this form is to report the following information on each resident of this state who has inforce more than one Medicare supplement policy or certificate. The information is to be grouped by individual policyholder.

Policy and Certificate #…Date of Issuance

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Signature

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Name and Title (please type)

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Date

Source

The provisions of this Appendix F adopted July 24, 1992, effective July 25, 1992, 22 Pa.B. 3841.