W. Va. Code R. agency 114, tit. 114, ser. 114-32, 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 producer on that producer's amount of long-term care insurance replacement sales as a percent of the producer's total annual sales and the amount of lapses of long-term care insurance policies sold by the producer as a percent of the producer's total annual sales. The tables below should be used to report the ten percent (10%) of the insurer's producers with the greatest percentages of replacements and lapses.
Listing of the 10% of Producers with the Greatest Percentage of Replacements
| Producer's Name | Number of Policies Sold By This Producer | Number of Policies Replaced By This Producer | Number of Replacements As % of Number Sold By This Producer |
Listing of the 10% of Producers with the Greatest Percentage of Lapses
| Producer's Name | Number of Policies Sold By This Producer | Number of Policies Lapsed By This Producer | Number of Lapses As % of Number Sold By This Producer |
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) _____%
W. Va. Code R. agency 114, tit. 114, ser. 114-32, app G