WAC 284-212-195

The following form must be used in this state to report replacements and lapses of supplemental long-term care insurance.

For the State of            For the Reporting Year of         

Company Name:                           

Due: June 30, Annually

Company Address:                        

Company NAIC Number:                    

Contact Person:                         Phone Number:                    

The purpose of this form is to report on a statewide basis information regarding supplemental long-term care insurance policy replacements and lapses. Specifically, every issuer must maintain records for each [agent] [insurance producer] on that [agent's] [insurance producer's] amount of supplemental long-term care insurance replacement sales as a percent of the [agent's] [insurance producer's] total annual sales and the amount of lapses of supplemental long-term care insurance policies sold by the [agent] [insurance producer] as a percent of the [agent's] [insurance producer's] total annual sales. The tables below should be used to report the ten percent of the issuer's [agents] [insurance producers] with the greatest percentages of replacements and lapses.

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)      %