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Bulletin No. 91-01

Forms with instructions issued pursuant to act 306 of the public acts of 1969, as amended

Issued and entered February 21, 1991 by Dominic A. D'Annunzio, Acting Commissioner of Insurance


The purpose of this bulletin is to clarify the provisions of and provide for the submission of information pursuant to Section 2272c of the Michigan Insurance Code, MCLA 500.2272c, MSA 24.12272c and Section 21054k of the Public Health Code, MCLA 333.21054K, MSA 14.15(21054k).

Under Section 2272c of the Insurance Code and Section 21054k of the Public Health Code, information is required to be reported to the commissioner for every individual resident of the state for which the company has in force multiple medicare supplemental coverage contracts, policies or certificates. Every company writing medicare supplemental coverage in Michigan must report the following information for each individual covered by more than one medicare supplemental contract, policy or certificate:

1. Name or identifier for the individual contract, policy or certificate holder.

2. Contract, policy or certificate number for each individual contract, policy or certificate.

3. Contract, policy or certificate number and member number for each group contract, policy or certificate.

4. Date of issuance for each contract, policy or certificate.


Attached is the Report of Multiple Medicare Supplemental Coverage in Force For Michigan Residents. Because of the unexpected delay in issuing this form, the Insurance Bureau will extend the deadline for reporting to April 1 for this year only. In the future, the information must be reported on the attached form or substantially similar form on or before March 1 of each year.

Completed forms should be returned to:

Senior Citizen Ombudsman
Michigan Insurance Bureau
P.O. Box 30220
Lansing, MI 48909


SUBMISSION REQUIRED BY: Insurers, HMOs and Health Care Corporations providing medicare supplemental coverage in Michigan. Due on or before March 1 each year


Name and address of company N.A.I.C. Group Code N.A.I.C. Company Code

Name and phone number of person to contact with questions regarding this report:

Instructions: Identify each Michigan resident for which the company has more than 1 medicare supplemental coverage plan in force. Give contract, policy or certificate number of each coverage plan in force, for each individual. Show date of issue of each coverage plan. If necessary, attach additional sheets, or a printout of the
information in the same format as this form. If additional pages are attached, include company name, NAIC company code and contact person with phone number on each page.

Covered Individual's Name or Identification Policy, Certificate and Contract Numbers Date of Issue Individual Plan Number Group Plan and Member Number

Certification: I certify that I have examined this report and any attachments submitted with it, and it is complete and correct.
Authorized signer Date signed
Authorized signers name and title (typed or printed)

Due on or before March 1, each year Return completed report
directly to:

P.O. BOX 30220

Do not return this report with company's Annual Statement

Michigan Public Act 170 of 1990, Sec. 2272c and Act 89 of the HMO Act of 1990, Sec. 21054k require insurers and health maintenance organizations to report to the Commissioner, information about every individual resident of this state for which the insurer has in force more than 1 medicare supplemental insurance policy, certificate or contract.

INS 308 (9/90) Michigan Insurance Bureau