N.H. Admin. Code Ins, ch. Ins 3600, pt. Ins 3601, 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 Lapses Policies to Total Annual Sales _____%
Percentage of Lapse Policies to Policies in Force (as of the end of the preceding calendar year) ____%
N.H. Admin. Code Ins, ch. Ins 3600, pt. Ins 3601, app G
The amended version of this appendix by New Hampshire Register Volume 35, Number 10, eff.2/13/2015 is not yet available.