Form LHL563 "Rescission Reporting Form for Long-Term Care Policies for the State of Texas" - Texas

What Is Form LHL563?

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

Form Details:

  • Released on February 1, 2018;
  • The latest edition provided by the Texas Department of 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 fillable version of Form LHL563 by clicking the link below or browse more documents and templates provided by the Texas Department of Insurance.

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Download Form LHL563 "Rescission Reporting Form for Long-Term Care Policies for the State of Texas" - Texas

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T
D
I
EXAS
EPARTMENT OF
NSURANCE
Regulatory Policy Division - Accident and Health Program (106-1D)
333 Guadalupe, Austin, Texas 78701 PO Box 149104, Austin, Texas 78714-9104
(512) 676-6630 | F: (512) 490-1017 | (800) 578-4677 | TDI.texas.gov | @TexasTDI
Rescission Reporting Form for
Figure 28 TAC §3.3837(b)
Long-Term Care Policies for the
State of Texas
Due: No later than June 30 annually for the preceding calendar year
For the Reporting Year of:
2019
Company NAIC Number:
Company Name:
Company Address:
City:
State:
ZIP:
Contact Name:
Contact Title:
Contact Email:
EXT:
Contact Phone Number:
Instructions:
The purpose of this form is to report all rescissions of long-term care insurance policies or certificates for the preceding
calendar year. Those rescissions voluntarily effectuated by an insured are not required to be included in this report.
Please furnish one form per rescission.
Date of Policy
Date(s) Claim(s)
Date of
Policy and
Policy Form #
Name of Insured
Issuance
Submitted
Rescission
Certificate #
MM/DD/YYYY
MM/DD/YYYY
MM/DD/YYYY
Detailed reason for rescission (1,000 character limit):
Submission Date:
4/15/20
Submit By Email
Print Form
LHL563 Rev. 2/2018
1/1
Texas Department of Insurance | www.tdi.texas.gov
T
D
I
EXAS
EPARTMENT OF
NSURANCE
Regulatory Policy Division - Accident and Health Program (106-1D)
333 Guadalupe, Austin, Texas 78701 PO Box 149104, Austin, Texas 78714-9104
(512) 676-6630 | F: (512) 490-1017 | (800) 578-4677 | TDI.texas.gov | @TexasTDI
Rescission Reporting Form for
Figure 28 TAC §3.3837(b)
Long-Term Care Policies for the
State of Texas
Due: No later than June 30 annually for the preceding calendar year
For the Reporting Year of:
2019
Company NAIC Number:
Company Name:
Company Address:
City:
State:
ZIP:
Contact Name:
Contact Title:
Contact Email:
EXT:
Contact Phone Number:
Instructions:
The purpose of this form is to report all rescissions of long-term care insurance policies or certificates for the preceding
calendar year. Those rescissions voluntarily effectuated by an insured are not required to be included in this report.
Please furnish one form per rescission.
Date of Policy
Date(s) Claim(s)
Date of
Policy and
Policy Form #
Name of Insured
Issuance
Submitted
Rescission
Certificate #
MM/DD/YYYY
MM/DD/YYYY
MM/DD/YYYY
Detailed reason for rescission (1,000 character limit):
Submission Date:
4/15/20
Submit By Email
Print Form
LHL563 Rev. 2/2018
1/1
Texas Department of Insurance | www.tdi.texas.gov