# COMAR Title 31 — Maryland Insurance Administration

## Subtitle 14 — Long-Term Care

### Chapter 01 — Long-Term Care Insurance

#### Regulation .29 Rescission.

*COMAR 31.14.01.29*

Reporting Form for Long-Term Care Policies. The following form is to be used for reporting rescissions made by each insurer as required by Regulation .09C of this chapter:

RESCISSION REPORTING FORM FOR LONG-TERM CARE POLICIES FOR THE STATE OF  FOR THE REPORTING YEAR 20[    ]

Company Name: _____________________

Address: _________________

Phone Number: _____________________

Due: March 1 annually

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.

Policy Form#
            Policy andCertificate #
            Name of Insured
            Date of Policy Issuance
            Date/sClaim/sSubmitted
            Date of Rescission

Detailed reason for rescission: _______________________________
          
          
            ______________________________________________________
          
          
            ___________________________Signature
          
          
            ___________________________Name and Title (please type)
          
          
            ___________________________Date