"Medicare Supplement Multiple Policy Report Form" - Oklahoma

Medicare Supplement Multiple Policy Report Form is a legal document that was released by the Oklahoma Insurance Department - a government authority operating within Oklahoma.

Form Details:

  • The latest edition currently provided by the Oklahoma Insurance Department;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Oklahoma Insurance Department.

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Download "Medicare Supplement Multiple Policy Report Form" - Oklahoma

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Multiple
Medicare Supplement
Policy Report
st
Company Name: ______________________________________ Due: March 1
Annually
Company Address: ______________________________________________________
______________________________________________________________________
Company NAIC Number: __________________
Oklahoma Co. Number: _________
Contact Person: _____________________ Phone Number: ______________________
Email Address: ________________________________
The purpose of this form is to report the following information on each resident of this state who
has in force more than one Medicare supplement policy or certificate. The information is to be
grouped by individual policyholder.
Date of
Policy and
Issuance
Certificate #
________________________________
Signature
________________________________
Name and Title (please type)
________________________________
Date
[Source: Added at 9 Ok Reg 549, eff 12/13/91 (emergency); Added at 9 Ok Reg 2499, eff 6/26/92;
Amended at 9 Ok Reg 3899, eff 8/24/92 (emergency); Amended at 10 Ok Reg 1475, eff 5/1/93]
Multiple
Medicare Supplement
Policy Report
st
Company Name: ______________________________________ Due: March 1
Annually
Company Address: ______________________________________________________
______________________________________________________________________
Company NAIC Number: __________________
Oklahoma Co. Number: _________
Contact Person: _____________________ Phone Number: ______________________
Email Address: ________________________________
The purpose of this form is to report the following information on each resident of this state who
has in force more than one Medicare supplement policy or certificate. The information is to be
grouped by individual policyholder.
Date of
Policy and
Issuance
Certificate #
________________________________
Signature
________________________________
Name and Title (please type)
________________________________
Date
[Source: Added at 9 Ok Reg 549, eff 12/13/91 (emergency); Added at 9 Ok Reg 2499, eff 6/26/92;
Amended at 9 Ok Reg 3899, eff 8/24/92 (emergency); Amended at 10 Ok Reg 1475, eff 5/1/93]