Form LTC-A "Rescission Reporting Form for Long-Term Care Policies for the State of Missouri" - Missouri

What Is Form LTC-A?

This is a legal form that was released by the Missouri Department of Commerce and Insurance - a government authority operating within Missouri. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on November 15, 2007;
  • The latest edition provided by the Missouri Department of Commerce and Insurance;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form LTC-A by clicking the link below or browse more documents and templates provided by the Missouri Department of Commerce and Insurance.

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Download Form LTC-A "Rescission Reporting Form for Long-Term Care Policies for the State of Missouri" - Missouri

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RESCISSION REPORTING FORM FOR
LONG-TERM CARE POLICIES
FOR THE STATE OF MISSOURI
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 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 (1) form per rescission.
Date of
Date/s
Policy
Policy and
Name of
Policy
Claim/s
Date of
Form #
Certificate #
Insured
Issuance
Submitted
Rescission
Detailed
reason
for
rescission:
________________________________________________________________________
___________________
________________________________________________________________________
____________________________________________
________________________________________________________________________
____________________________________________
________________________________________________________________________
____________________________________________
________________________________________________________________________
____________________________________________
__________________________________
Signature
RESCISSION REPORTING FORM FOR
LONG-TERM CARE POLICIES
FOR THE STATE OF MISSOURI
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 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 (1) form per rescission.
Date of
Date/s
Policy
Policy and
Name of
Policy
Claim/s
Date of
Form #
Certificate #
Insured
Issuance
Submitted
Rescission
Detailed
reason
for
rescission:
________________________________________________________________________
___________________
________________________________________________________________________
____________________________________________
________________________________________________________________________
____________________________________________
________________________________________________________________________
____________________________________________
________________________________________________________________________
____________________________________________
__________________________________
Signature
__________________________________
Name and Title (please type)
__________________________________
Date
LTC-A
(Rev 11/15/2007)
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