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WAC 284-212-165

Form for reporting rescission of supplemental long-term care insurance policies.

The following form must be used by issuers to annually report rescission of supplemental long-term care insurance policies.
RESCISSION REPORTING FORM FOR SUPPLEMENTAL LONG-TERM CARE INSURANCE POLICIES FOR THE STATE
OF        FOR THE REPORTING YEAR 20[ ]
Company Name:                         
Address:                              
                                      
Phone Number:                         
Due: March 1, annually
Instructions: The purpose of this form is to report all rescissions of supplemental 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:                
                                               
                                               
                                               
                                               
                                     
Signature
                                     
Name and Title (please type)
                                     
Date
[Statutory Authority: RCW 48.02.060 (3)(a), 48.85.030(1), 48.212.140, 48.212.150, 48.212.170, 48.212.200, and 48.85.030. WSR 26-05-001 (Matter R 2025-06), s 284-212-165, filed 2/4/26, effective 3/7/26.]
Reviser's note: The brackets and enclosed material in the text of the above section occurred in the copy filed by the agency.