DEPARTMENT OF LABOR AND REGULATION

DIVISION OF INSURANCE

REPLACEMENT AND LAPSE REPORTING FORM

Chapter 20:06:21

APPENDIX J

SEE: § 20:06:21:52

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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 percentage 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 (asoftheendoftheprecedingcalendaryear) _____%

Percentage of Lapsed Policies to Total Annual Sales _____%

Percentage of Lapsed Policies to Policies In Force (asoftheendoftheprecedingcalendaryear) _____%

Source: 28 SDR 157, effective May 19, 2002.