23 CAR pt. 87, Appendix G
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:
(_) _______
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.
| 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 |
|---|---|---|---|
| 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 |
|---|---|---|---|
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) ____%