New York Codes, Rules and Regulations
Title 11 - INSURANCE
Appendices
Appendix 10A - DEPARTMENT OF FINANCIAL SERVICES OF THE STATE OF NEW YORK

Current through Register Vol. 45, No. 52, December 27, 2023

DISCLOSURE STATEMENT

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

* IMPORTANT 60 DAY REFUND PERIOD:

IF YOU ARE NOT SATISFIED WITH YOUR NEW LIFE INSURANCE POLICY OR ANNUITY CONTRACT YOU HAVE THE RIGHT, WITHIN 60 DAYS FROM THE DATE OF DELIVERY OF YOUR POLICY OR 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 policy 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

Existing coverage to be changed by:

Use of cash released:____________________________________________________________________________

AGENT'S OR BROKER'S STATEMENT:

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

______________________________________________________________________________

______________________________________________________________________________

2. The existing life insurance policy or annuity contract cannot meet the applicant's objectives because:

______________________________________________________________________________

______________________________________________________________________________

3. The advantages of continuing the existing life insurance policy or annuity contract without changes are:

______________________________________________________________________________

______________________________________________________________________________

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

Date: ____________________________ Signature of Applicant: _______________________

*** Applicant Acknowledgment may be included or omitted at insurer's option.

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