APPENDIX A
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 this state who has in force more than one medicare supplement policy or certificate. The information is to be grouped by individual policyholder. Policy and Date of Certificate #Issuance _________ _________ _________ _________ _________ _________ _________ _________ _________ Signature _________ Name and Title (please type) _________ Date
3 AAC 28.506
In 2010 the revisor of statutes, acting under AS 01.05.031, renumbered former AS 21.89.060 as AS 21.96.060. As of Register 196 (January 2011), the regulations attorney made a conforming technical revision under AS 44.62.125(b)(6), to the authority citation that follows 3 AAC 28.506, so that the citation to former AS 21.89.060 now refers to the renumbered statute, AS 21.96.060.
Authority:AS 21.06.090
AS 21.42.130
AS 21.96.060