Regulation .20 Form for Reporting Multiple Policies.

The following form is to be used in making reports of multiple policies in accordance with the requirements of Regulation .17 of this chapter:

(a)3	(b)4	(c)	(d)	(e)	(f)	(g)	(h)	(i)	(j)	(o)5
Year	Earned Premium	Factor	(b) × (c)	Cumulative Loss Ratio	(d) × (e)	Factor	(b) × (g)	Cumulative Loss Ratio	(h) × (i)	Policy Year Loss Ratio
1		2.770		0.442		0.000		0.000		0.4
2		4.175		0.493		0.000		0.000		0.55
3		4.175		0.493		1.194		0.659		0.65
4		4.175		0.493		2.245		0.669		0.67
5		4.175		0.493		3.170		0.678		0.69
6		4.175		0.493		3.998		0.686		0.71
7		4.175		0.493		4.754		0.695		0.73
8		4.175		0.493		5.445		0.702		0.75
9		4.175		0.493		6.075		0.708		0.76
10		4.175		0.493		6.650		0.713		0.76
11		4.175		0.493		7.176		0.717		0.76
12		4.175		0.493		7.655		0.720		0.77
13		4.175		0.493		8.093		0.723		0.77
14		4.175		0.493		8.493		0.725		0.77
15+6		4.175		0.493		8.684		0.725		0.77
			________		________		________		________
Total:		(k):		(l):		(m):		(n):

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.

FORM FOR REPORTING MEDICARE SUPPLEMENT POLICIES
Company name:	________________________________________
Address:	________________________________________
	________________________________________
Phone Number:	________________________________________
	Due: March 1, annually

Policy and Certificate #	Date of Issuance