Form for reporting replacement and lapse of long-term care insurance policies.
The following form must be used in this state to report replacements and lapses of long-term care insurance.
Long-Term Care Insurance Replacement and Lapse Reporting Form
For the State of For the Reporting Year of
Company Name:
Due: June 30, Annually
Company Address:
Company NAIC Number:
Contact Person: Phone Number:
Instructions
The purpose of this form is to report on a statewide basis information regarding long-term care insurance policy replacements and lapses. Specifically, every issuer must maintain records for each [agent] [insurance producer] on that [agent's] [insurance producer's] amount of long-term care insurance replacement sales as a percent of the [agent's] [insurance producer's] total annual sales and the amount of lapses of long-term care insurance policies sold by the [agent] [insurance producer] as a percent of the [agent's] [insurance producer's] total annual sales. The tables below should be used to report the ten percent of the issuer's [agents] [insurance producers] with the greatest percentages of replacements and lapses.
Listing of the 10% of [Agents] [Insurance Producers] with the Greatest Percentage of Replacements
[Agent's] [Insurance Producer's] Name | Number of Policies Sold by This [Agent] [Insurance Producer] | Number of Policies Replaced by This [Agent] [Insurance Producer] | Number of Replacements as % of Number Sold by This [Agent] [Insurance Producer] |
| | | |
Listing of the 10% of [Agents] [Insurance Producers] with the Greatest Percentage of Lapses
[Agent's] [Insurance Producer's] Name | Number of Policies Sold by This [Agent] [Insurance Producer] | Number of Policies Lapsed by This [Agent] [Insurance Producer] | Number of Lapses as % of Number Sold by This [Agent] [Insurance Producer] |
| | | |
Company Totals
Percentage of Replacement Policies Sold to Total Annual Sales %
Percentage of Replacement Policies Sold to Policies In Force (as of the end of the preceding calendar year) %
Percentage of Lapsed Policies to Total Annual Sales %
Percentage of Lapsed Policies to Policies In Force (as of the end of the preceding calendar year) %
Reviser's note: The brackets and enclosed material in the text of the above section occurred in the copy filed by the agency.