Pa. Code tit. 31, pt. IV, ch. 89a, app G - 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 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)

___

%

Notes

Pa. Code tit. 31, pt. IV, ch. 89a, app G

This appendix cited in 31 Pa. Code § 89a.114 (relating to reporting requirements).