WAC 284-212-054

The following form must be used by issuers to annually report independent third-party review appeal decisions concerning changes made by issuers for supplemental long-term care policyholders under RCW 48.212.090(2).

Company Name:                         

Address:                              

Phone Number:                         

Independent Third-Party Reviewer Name:                         

Address:                              

Phone Number:                         

Website Address:                              

Due: March 1, annually

Instructions: The purpose of this form is to report all independent third-party review appeal requests and decisions. Please furnish one form per each independent third-party reviewer decision.

Detailed reason for initial issuer determination and independent third-party reviewer decision:                

Signature

Name and Title (please type)

Date