§2008.APPENDIX U. Medicare Supplement Policies Report

Latest version.

Company Name:

Address:

Phone Number:

Due: March 1, annually

The purpose of this report is to provide information on each resident of this State who has 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

(Source: Appendix U renumbered from Appendix P at 29 Ill. Reg. 14188, effective September 8, 2005)

                    
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Company Name:
Address:

Phone Number:

Policy and Certificate #	Date of Issuance