(1) It is an unfair method of competition and an unfair practice for an insurer to permit a licensed insurance producer, whether appointed by the insurer or not, to solicit an individual in the state of Washington to buy or apply for life insurance, annuities, or disability insurance coverage when the coverage is provided under the terms of a group policy delivered to an association or organization (or to a trustee designated by the association or organization), as policyholder, outside this state, unless the following steps are taken:

(a) An accurately completed disclosure statement, substantially in the form set forth in subsection (2) of this section, must be brought to the attention of the individual being solicited before the application for coverage is completed and signed. The disclosure form must be signed by both the soliciting licensee and the individual being solicited and it must be given to the individual.

(b) A copy of the completed disclosure statement must be submitted by the soliciting licensee, with the application for coverage, to the insurer providing the coverage.

(c) The insurer must confirm the accuracy of the form's contents, and retain the copy for not less than three years from the date the coverage commences or from the date received, whichever is later.

(2) Disclosure statement form: (Type size to be no less than ten-point)

Save this statement! It may be important to you in the future. The Washington State Insurance Commissioner requires that we give you the following information about the coverage offered to you under a group policy issued by    (insurer)   ,    (to/on behalf of)     (association or organization)    .

The policy is subject to and governed by the laws of the state of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

The certificate of coverage issued to you is governed by the state of Washington.

The Washington State Insurance Commissioner has authority to assist you concerning your coverage.

To keep this coverage, you    (must/need not)    continue membership in the group. If you are not now a member, the initial cost of membership is $ . . . . Additional dues or membership fees are currently $ . . . . per . . . . Membership costs    (may/will not)    increase in future years. You will also have the premiums to pay.

The coverage    (can/can not)    be discontinued by the group. It    (can/can not)    be terminated by the insurer. If the group organization ceases to exist, your coverage    (would/would not)    terminate. You    (are/are not)    entitled by the contract to convert your coverage to your own policy.

   (Group organization's name)    (will/will not)    be paid for its participation in this insurance program.    (An explanation of payments must be inserted here.)   .

If you apply for this coverage, you    (will/will not)    have a "free look" (of . . . . days*) during which you may cancel your contract and recover your premium without obligation. Your membership fee to join the group    (is/is not)    refundable. *(Omit phrase, "of . . . . days", if there is no "free look.")

delivered to the applicant this . . . . . . . day of (month) , (year) , by

(Signed) . . . . . . . . . . . . . . . . . . (insurance producer).

Printed Name: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

i acknowledge that i have received and understand this disclosure statement: . . . . . Applicant.

(3) This section does not apply with respect to coverage provided to individuals under a group contract which is provided for a group of a type described in RCW 48.24.035, 48.24.040, 48.24.060, 48.24.080, 48.24.090, or 48.24.095.