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

Current through Register Vol. 46, No. 45, November 2, 2024

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

DISCLOSURE STATEMENT (Annuity-to-Annuity Replacement Only)

IMPORTANT - IT MAY NOT BE IN YOUR BEST INTEREST TO SURRENDER, LAPSE, CHANGE OR BORROW FROM EXISTING ANNUITY CONTRACTS IN CONNECTION WITH THE PURCHASE OF A NEW ANNUITY 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 CONTRACT. PLEASE REVIEW THIS DOCUMENT CAREFULLY AS IT CONTAINS IMPORTANT COMPARISON INFORMATION BETWEEN YOUR EXISTING CONTRACT AND THE NEW CONTRACT.

* IMPORTANT 60 DAY REFUND PERIOD:

IF YOU ARE NOT SATISFIED WITH YOUR NEW ANNUITY CONTRACT YOU HAVE THE RIGHT, WITHIN 60 DAYS FROM THE DATE OF DELIVERY OF YOUR 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 contract 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 Annuity Contract	Existing Annuity Contracts Affected
(1)	(2)	(3)
__________________	Company	____________	____________	_____________
_______-__________	Customer Service Telephone Number:	____-_______	____-_______	____-________
__________________	Type of Annuity	____________	____________	_____________
Contract Number	# __________	# __________	# ___________
Issue Date	____________	____________	_____________
$_________________	Account Value	$___________	$___________	$____________
$_________________	Minus Surrender Charge	$___________	$___________	$____________
$_________________	Plus/Minus Market Value Adjustment (if any)	$___________	$___________	$____________
$_________________	Equals Surrender Value	$___________	$___________	$____________

2. SUMMARY RESULT COMPARISON:
THE PROPOSED ANNUITY					IF YOU CONTINUE YOUR CURRENT ANNUITY
Surrender Value To Be Invested: $ _________						Current Value $ _________
If Variable Annuity Hypothetical Rates of Return						If Variable Annuity Hypothetical Rates of Return
At Guaranteed Rate	At Current Rate	@ 0%	@ 6%	@ 12%	At uaranteed Rate	At Current Rate	@ 0%	@ 6%	@ 12%
SURRENDER VALUE
$_____	$_____	$	$_____	$ ____ In 5 Yrs	$_____	$_____	$_____	$_____	$_____
$_____	$_____	$_____	$_____	$ ____ In 10 Yrs	$______	$_____	$_____	$_____	$_____
DEATH BENEFIT
$_____	$_____	$_____	$_____	$ ____ In 5 Yrs	$_____	$_____	$_____	$_____	$_____
$_____	$_____	$_____	$_____	$ ____ In 10 Yrs	$______	$_____	$_____	$_____	$_____

AGENT'S OR BROKER'S STATEMENT:

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

___________________________________________________________________________

2. The existing annuity contract cannot meet the applicant's objectives because:

___________________________________________________________________________

3. The advantages of continuing the existing annuity contract without changes are:

___________________________________________________________________________

4. The surrender charge, if my client replaces his or her existing annuity contract, is___% or $___. The new annuity my client is applying for imposes a new surrender charge as follows:

(Describe percentage rate of surrender charge for each year in which a surrender charge is imposed)

__________________________________________________________________________________________

_________________________________________________________________________________________

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 annuity contracts are to be affected by this transaction, or if more than one new annuity contract is proposed, Section 1 of this Disclosure Statement must be completed for such additional annuity contracts. In addition, a composite comparison shall be completed for all existing annuity contracts to all proposed 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 10B

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