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Virginia Administrative Code
Title 14. Insurance
Agency 5. State Corporation Commission, Bureau of Insurance
Chapter 170. Rules Governing Minimum Standards for Medicare Supplement Policies
12/26/2024

14VAC5-170-220:2. APPENDIX B. FORM FOR REPORTING MEDICARE SUPPLEMENT POLICIES.

APPENDIX B

8/05

APPENDIX B
FORM FOR REPORTING MEDICARE SUPPLEMENT POLICIES

Company Name:_____________________________

Address:___________________________________

__________________________________________

Phone Number: ______________________________

Due March 1, annually

The purpose of this form is to report the following information on each resident of Virginia who has in force more than one Medicare supplement policy or certificate. The information is to be grouped by individual policyholder.

Policy and Certificate #

Date of Issuance

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

___________________________________________

Signature

___________________________________________

Name and Title (please type)

___________________________________________

Date

Statutory Authority

§§ 12.1-13 and 38.2-223 of the Code of Virginia.

Historical Notes

Derived from Regulation 35, Case No. INS920112, § 19, eff. July 30, 1992; amended, Virginia Register Volume 21, Issue 25, eff. August 15, 2005.

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