Pa. Code tit. 31, pt. IV, ch. 89a, app G
| 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)
___
%
Pa. Code tit. 31, pt. IV, ch. 89a, app G
This appendix cited in 31 Pa. Code § 89a.114 (relating to reporting requirements).