N.Y. Comp. Codes R. & Regs. tit. 11, Appendices, app 10A

Current through Register Vol. 46, No. 50, December 11, 2024

Appendix 10A - DEPARTMENT OF FINANCIAL SERVICES OF THE STATE OF NEW YORK

DISCLOSURE STATEMENT

IMPORTANT - IT MAY NOT BE IN YOUR BEST INTEREST TO SURRENDER, LAPSE, CHANGE OR BORROW FROM EXISTING LIFE INSURANCE POLICIES OR ANNUITY CONTRACTS IN CONNECTION WITH THE PURCHASE OF A NEW POLICY OR CONTRACT WHETHER ISSUED BY THE SAME OR A DIFFERENT INSURANCE COMPANY

* THIS DISCLOSURE STATEMENT IS REQUIRED TO BE PROVIDED TO YOU NO LATER THAN UPON DELIVERY OF THE NEW POLICY OR CONTRACT. PLEASE REVIEW THIS DOCUMENT CAREFULLY AS IT CONTAINS IMPORTANT COMPARISON INFORMATION BETWEEN YOUR EXISTING INSURANCE POLICY OR ANNUITY CONTRACT AND THE NEW POLICY OR CONTRACT.

* IMPORTANT 60 DAY REFUND PERIOD:

IF YOU ARE NOT SATISFIED WITH YOUR NEW LIFE INSURANCE POLICY OR ANNUITY CONTRACT YOU HAVE THE RIGHT, WITHIN 60 DAYS FROM THE DATE OF DELIVERY OF YOUR POLICY OR CONTRACT, TO RETURN IT AND RECEIVE A REFUND.

* PLEASE CONTACT THE COMPANY, AGENT OR BROKER IF YOU HAVE ANY QUESTIONS.

FOR YOUR PROTECTION, the Department of Financial Services of the State of New York requires that you be given this Disclosure Statement with policy information on all proposed and existing coverage affected.

Name of Applicant______________________________Telephone# ________________

Address_________________________________________________________________________

Name of Agent or Broker_________________________Telephone #_________________________

Company______________________________________Address___________________________

The information on existing coverage on this form was obtained from

____the replaced company

____approximations if replaced company failed to provide information in the prescribed time

1. DESCRIPTION OF TRANSACTION:		AS OF DATE:
Proposed Policy/Contract		Existing Policies/Contracts Affected
		(1)	(2)	(3)
____________	Company	____________	____________	____________
_______-__________	Customer Service Telephone Number	:____-_______	____-_______	____-_______
____________	Type of Insurance	____________	____________	____________
$___________	Face Amount	$___________	$___________	$___________
$___________	Rider _________	$___________	$___________	$___________
$___________	Rider _________	$___________	$___________	$___________
$___________	Rider _________	$___________	$___________	$___________
$___________	Rider _________	$___________	$___________	$___________
$___________	Rider _________	$___________	$___________	$___________
$___________	Premium	$___________	$___________	$___________
Contract Number	# __________	# __________	# __________
Issue Date	____________	____________	____________
$__________	Surrender Charge	$___________	$___________	$___________
__________ %	Guaranteed Interest Rate	__________ %	__________ %	__________ %
__________ %	Loan Interest Rate	__________ %	__________ %	__________ %
__________ Years	Contestable Expiry Date	________ M/Y	________ M/Y	________ M/Y
__________ Years	Suicide Expiry Date	________ M/Y	________ M/Y	________ M/Y

Existing coverage to be changed by:

Lapse or Surrender	[ ]	[ ]	[ ]
Amendment or Reissue	[ ]	[ ]	[ ]
Loan or Withdrawal	[ ]	[ ]	[ ]
Reduction To	$___________	$___________	$___________
Reduced Paid-Up For	$___________	$___________	$___________
Extended Term For	___Yrs___Mos	___Yrs___Mos	___Yrs___Mos

Cash released by change	Year _________	$___________	$___________	$___________
Year _________	$___________	$___________	$___________
Year _________	$___________	$___________	$___________

Use of cash released:____________________________________________________________________________

2. SUMMARY RESULT COMPARISON:
New With Existing Coverage Changed		Existing Coverage Unchanged
Guaranteed	Non-Guaranteed	Annual Premium	Guaranteed	Non-Guaranteed
$__________	$__________	At Present	$__________	$__________
$__________	$__________	5 Years Hence	$__________	$__________
$__________	$__________	10 Years Hence	$__________	$__________
Guaranteed	Non-Guaranteed	Surrender Value	Guaranteed	Non-Guaranteed
$__________	$__________	At Present	$__________	$__________
$__________	$__________	5 Years Hence	$__________	$__________
$__________	$__________	10 Years Hence	$__________	$__________
Guaranteed	Non-Guaranteed	Death Benefit	Guaranteed	Non-Guaranteed
$__________	$__________	At Present	$__________	$__________
$__________	$__________	5 Years Hence	$__________	$__________
$__________	$__________	10 Years Hence	$__________	$__________
Guaranteed	Non-Guaranteed	Dividends	Guaranteed	Non-Guaranteed
$__________	$__________	At Present	$__________	$__________
$__________	$__________	5 Years Hence	$__________	$__________
$__________	$__________	10 Years Hence	$__________	$__________

AGENT'S OR BROKER'S STATEMENT:

1. The primary reason(s) for recommending the new life insurance policy or annuity contract is (are):

______________________________________________________________________________

2. The existing life insurance policy or annuity contract cannot meet the applicant's objectives because:

______________________________________________________________________________

3. The advantages of continuing the existing life insurance policy or annuity contract without changes are:

______________________________________________________________________________

REMARKS:

______________________________________________________________________________

[] Sales material, including proposal, was used in this sale.

[] No sales material or proposal was used in this sale.

If more than three existing life insurance policies or annuity contracts are to be affected by this transaction, or if more than one new life insurance policy or annuity contract is proposed, Section 1 of this Disclosure Statement must be completed for such additional life insurance policies and annuity contracts. In addition, a composite comparison shall be completed for all existing life insurance policies or annuity contracts to all proposed life insurance policies or annuity contracts. Sales material, including any proposal used, has been provided to the insurer. Copies of the sales material and any proposal have also been given to the applicant.

I have personally completed this form and certify that it is correct to the best of my knowledge and ability.

Date: ____________________________ Signature of Agent or Broker: ___________________

*** Applicant Acknowledgement

I hereby acknowledge that I received and read the above "Disclosure Statement."

Date: ____________________________ Signature of Applicant: _______________________

*** Applicant Acknowledgment may be included or omitted at insurer's option.

N.Y. Comp. Codes R. & Regs. tit. 11, Appendices, app 10A

Adopted, New York State Register January 21, 2015/Volume XXXVII, Issue 03, eff. 4/21/2015