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