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(a) Annually, on or before March 1, every issuer or other entity providing medicare supplement insurance coverage in this state shall report the following information, on the reporting form contained in Appendix A of this section, for every individual resident of this state for which the issuer or other entity has in force more than one medicare supplement insurance policy or certificate:
(1) policy and subscriber control number; and
(2) date of issuance.
(b) The information required by (a) of this section must be grouped by individual policyholder.
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 who has in force more than one medicare supplement policy or certificate. The information is to be grouped by individual policyholder.
Policy and Date of Certificate # Issuance ________________________________________ ________________________________ ________________________________________ ________________________________ ________________________________________ ________________________________ ________________________________________ ________________________________ ____________________________________________________________ Signature ____________________________________________________________ Name and Title (please type) ____________________________________________________________ Date
History: Eff. 8/8/90, Register 115; am 7/1/92, Register 122; am 7/12/96, Register 139
Authority: AS 21.06.090
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Last modified 7/05/2006