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PDFWAC 284-23-485

Form to be used for notice regarding replacement.

(Insurance company's name and address)
important notice regarding replacement of
(Save this notice! It may be important to you in the future.)
The decision to buy a new life insurance policy or annuity and discontinue or change an existing one is very important. Your decision could be a good one—or a mistake. It should be carefully considered. The Washington state insurance commissioner requires us to give you this notice to help you make a wise decision.
statement to applicant by insurance producer:
(Use additional sheets, as necessary.)
I believe the replacement of insurance involved in this transaction materially improves your position. My conclusion has taken into account the following factors, which I call to your attention.
1. Can there be reduced benefits or increased premiums in later years? . . . No . . . Yes, explain:
2. Are there penalties, set up or surrender charges for the new policy? . . . No . . . Yes, explain, emphasizing any extra cost for early withdrawal:
3. Will there be penalties or surrender charges under the existing insurance as a result of the proposed transaction? . . . No . . . Yes, explain:
4. Are there adverse tax consequences from the replacement under current tax law? . . . No . . . Yes, explain:
a)Are interest earnings a consideration in this replacement? No . . . . Yes . . . .
b)If "yes," explain what portions of premiums or contributions will produce limited or no earnings. As pertinent, include in your explanation the need for minimum deposits to enhance earnings, and the reduction of earnings that may result from set-up charges, policy fees, and other factors.
6. Are minimum amounts required to be on deposit before excess interest will be paid? . . . No . . . Yes, explain:
7. If the new program is based on a variable or universal life insurance policy or a single-premium policy or annuity:
a)Are the interest rates quoted before . . . or after . . . fees and mortality charges have been deducted?
b)Interest rates are guaranteed for how long? . . .
c)The minimum interest rate to be paid is how much? . . .
d)If applicable, the rate you pay to borrow is . . . . . , and the limit on the amount that can be borrowed is . . . . .
e)The surrender charges are . . . . .
f)The death benefit is . . . . .
8. Are there other short or long term effects from the replacement that might be materially adverse? . . . No . . . Yes, explain:
. . . .
Signature of Insurance Producer
. . . .
. . . .
Name of Insurance Producer
(Print or Type)
. . . .
. . . .
List of Policies or Contracts to be Replaced:
Contract No.
caution: The insurance commissioner suggests you consider these points:
˃ Usually, contestable and suicide periods start again under a new policy. Benefits might be excluded under a new policy that would be paid under existing insurance.
˃ Terminating or altering existing coverage, before new insurance has been issued, might leave you unable to purchase other life insurance or let you buy it only at substantially higher rates.
˃ You are entitled to advice from the existing insurance producer or company. Such advice might be helpful.
˃ Study the comments made above by the insurance producer. They apply to you and this proposal. They are important to you and your future.
Completed Copy
Received: . . . .
(Applicant's Signature)
this completed form should be filed permanently with your new insurance policy.
[Statutory Authority: RCW 48.02.060 (3)(a) and 48.17.010(5). WSR 11-01-159 (Matter No. R 2010-09), § 284-23-485, filed 12/22/10, effective 1/22/11. Statutory Authority: RCW 48.02.060. WSR 87-14-015 (Order R 87-6), § 284-23-485, filed 6/23/87, effective 9/1/87.]
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