DEPARTMENT OF LABOR AND REGULATION

 

DIVISION OF INSURANCE

 

 

 

 

REPLACEMENT AND LAPSE REPORTING FORM

 

 

Chapter 20:06:21

 

APPENDIX J

 

SEE: § 20:06:21:52

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

          Source: 28 SDR 157, effective May 19, 2002.

 

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 insurer shall maintain records for each agent on that agent's amount of long-term care insurance replacement sales as a percent of the agent's total annual sales and the amount of lapses of long-term care insurance policies sold by the agent as a percent of the agent's total annual sales. The tables below should be used to report the ten percent (10%) of the insurer's agents with the greatest percentage of replacements and lapses.

 

Listing of the 10% of Agents with the Greatest Percentage of Replacements

 

Agent's Name	Number of Policies Sold By This Agent	Number of Policies Replaced by This Agent	Number of Replacements As % of Number Sold By This Agent

 

Listing of the 10% of Agents with the Greatest Percentage of Lapses

 

Agent's Name	Number of Policies Sold By This Agent	Number of Policies Lapsed By This Agent	Number of Lapses As % of Number Sold By This Agent

 

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) _____%