APPENDIX G RESCISSION REPORTING FORM FOR

LONG-TERM CARE POLICIES FOR THE STATE OF                                         FOR THE REPORTING YEAR         

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 effectu- ated by an insured are not required to be included in this report. Please furnish one form per rescission.

Policy Form #	Policy and Certificate #	Name of Insured	Date of Policy Issuance	Date/s Claim/s Submitted	Date of Rescission

Detailed reason for rescission:

Signature

Name and Title (please type)

Date

Historical Note

New Appendix G made by final rulemaking at 10 A.A.R. 4661, effective January 3, 2005 (Supp. 04-4).