INSTRUCTIONS: CONNECTICUT REQUEST FOR RESCISSION, CANCELLATION OR LIMITATION OF A HEALTH INSURANCE POLICY

To request the rescission, cancellation or limitation of a Connecticut health insurance policy administered by the state's insurance department, the form discussed in this article should be submitted. This document can be obtained from the website of the government of Connecticut.

Connecticut Request For Rescission, Cancellation Or Limitation Of A Health Insurance Policy Step 1: Enter the name of the insurance carrier or health care center on the first blank line.

Connecticut Request For Rescission, Cancellation Or Limitation Of A Health Insurance Policy Step 2: Enter the NAIC number of the insurance carrier or health care center on the second blank line.

Connecticut Request For Rescission, Cancellation Or Limitation Of A Health Insurance Policy Step 3: Enter the address of the insurance carrier or health care center on the third and fourth blank lines.

Connecticut Request For Rescission, Cancellation Or Limitation Of A Health Insurance Policy Step 4: Enter the name of a contact person for the insurance carrier or health care center on the fifth blank line.

Connecticut Request For Rescission, Cancellation Or Limitation Of A Health Insurance Policy Step 5: Enter the telephone number of the insurance carrier or health care center on the sixth blank line.

Connecticut Request For Rescission, Cancellation Or Limitation Of A Health Insurance Policy Step 6: Enter the name of the insured on the seventh blank line.

Connecticut Request For Rescission, Cancellation Or Limitation Of A Health Insurance Policy Step 7: Enter the department name which employs the insured on the eighth blank line.

Connecticut Request For Rescission, Cancellation Or Limitation Of A Health Insurance Policy Step 8: Enter the address of the insured on the ninth blank line.

Connecticut Request For Rescission, Cancellation Or Limitation Of A Health Insurance Policy Step 9: Enter the insurance identification number of the insured on the tenth blank line.

Connecticut Request For Rescission, Cancellation Or Limitation Of A Health Insurance Policy Step 10: Indicate whether this is a group policy or an individual policy by circling the appropriate statement.

Connecticut Request For Rescission, Cancellation Or Limitation Of A Health Insurance Policy Step 11: Enter the insurance policy number on the eleventh blank line.

Connecticut Request For Rescission, Cancellation Or Limitation Of A Health Insurance Policy Step 12: Enter the effective date of the policy on the twelfth blank line.