K Replacement and Lapse Reporting Form

Section 2012.EXHIBIT K   Replacement and Lapse Reporting Form Long-Term Care Insurance Replacement and Lapse Reporting Form For the State of 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 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) %