Appendix C "Rescission Report" - Oklahoma

What Is Appendix C?

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

Form Details:

  • The latest edition provided by the Oklahoma Insurance Department;
  • 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 fillable version of Appendix C by clicking the link below or browse more documents and templates provided by the Oklahoma Insurance Department.

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Download Appendix C "Rescission Report" - Oklahoma

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Appendix C
Rescission Report
Company Name: ____________________________________
Due: March 1 Annually
Company Address: _________________________________________________________
_________________________________________________________________________
Company NAIC Number: ____________________________________________________
Oklahoma Company Number: ___________
Contact Person: _____________________ Phone Number: __________________________
Line of Business:
Individual:
Group:
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 form per rescission.
Date
Date(s)
Policy Form No.
Policy and
Name of
of Policy
Claims(s)
Date of
Certificate No.
Insured
Issuance
Submitted
Rescission
Detailed reason for rescission: _____________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
____________________________
Signature
____________________________
Name and Title
____________________________
Date
Ref: See 365:10-5-44.1(e). Maintain record of rescissions.
Reset Form
Appendix C
Rescission Report
Company Name: ____________________________________
Due: March 1 Annually
Company Address: _________________________________________________________
_________________________________________________________________________
Company NAIC Number: ____________________________________________________
Oklahoma Company Number: ___________
Contact Person: _____________________ Phone Number: __________________________
Line of Business:
Individual:
Group:
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 form per rescission.
Date
Date(s)
Policy Form No.
Policy and
Name of
of Policy
Claims(s)
Date of
Certificate No.
Insured
Issuance
Submitted
Rescission
Detailed reason for rescission: _____________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
____________________________
Signature
____________________________
Name and Title
____________________________
Date
Ref: See 365:10-5-44.1(e). Maintain record of rescissions.