WAC 284-212-195. Form for reporting replacement and lapse of supplemental long-term care insurance policies

The following form must be used in this state to report replacements and lapses of supplemental long-term care insurance. Supplemental 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 supplemental 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 supplemental 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 supplemental 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] [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] [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) %