760 IAC 1-16.1-12.5 Exhibit A; notice regarding replacement

Sec. 12.5. EXHIBIT A IMPORTANT NOTICE REGARDING REPLACEMENT OF LIFE INSURANCE If you are thinking about DISCONTINUING or CHANGING an existing life insurance policy or annuity contract and BUYING a replacement, your decision could be a good one – or possibly a mistake. Make sure that you understand the facts. You should: –Make a careful comparison of your existing policy and the proposed policy. –Ask the company or agent that sold you your existing policy to provide you with complete information about it. –Consider both sides before you decide. –Determine what you want your insurance program to do. –Consider your present health. You may have had a change which could affect your insurability, so make sure to continue your present policy until a new policy is delivered to you and accepted by you. This form MUST be completed in triplicate and the original given to you by the agent proposing replacement no later than at the time you apply for the new policy. (This form must be completed and given to you even though the proposed replacement policy is with the same company that sold you your existing policy.) EXISTING POLICY INFORMATION on _____________________________ (Name of Insured) COMPANY TYPE OF POLICY POLICY NO. DATE OF ISSUE FACE AMOUNT OF BASIC POLICY TYPE OF OPTIONAL BENEFITS (If more policies are involved, use additional sets of forms) PROPOSED POLICY INFORMATION on (Name of Insured) COMPANY TYPE OF* POLICY FACE AMOUNT OF BASIC POLICY TYPE OF OPTIONAL BENEFITS Indiana Department of Insurance Regulation, 760 IAC 1-16.1 requires that the company making the replacement notify your existing insurance company that you may be replacing your existing policy. (You have the right, within twenty days after delivery of a replacement policy, to return it to the company and to claim an unconditional refund of all premiums paid on it.) Applicant's/Insured's Signature Replacing Agent's Signature Date Address Telephone Number * As shown on face of policy Indiana License Number