Appendix A.

RESCISSION REPORTING FORM FOR LONG-TERM CARE POLICIES FOR THE STATE OF

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FOR THE REPORTING YEAR 20[

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Company Name:

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Address:

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Phone Number:

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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 #

Policy and Certificate #

Name of Insured

Date of Policy Issuance

Date/s Claim/s Submitted

Date of Rescission

Detailed reason for rescission:

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Signature

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Name and Title (please type)

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Date

Cross References

This appendix cited in 31 Pa. Code § 89a.110 (relating to prohibition against postclaims underwriting).