23 CAR pt. 87, Appendix G. Long-Term Care Insurance Replacement and Lapse Reporting Form

APPENDIX G 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 percentages 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) _____%