New York Codes, Rules and Regulations
Title 11 - INSURANCE
Appendices
Appendix 10B - DEPARTMENT OF FINANCIAL SERVICES OF THE STATE OF NEW YORK
DISCLOSURE STATEMENT (Annuity-to-Annuity Replacement Only)
IMPORTANT - IT MAY NOT BE IN YOUR BEST INTEREST TO SURRENDER, LAPSE, CHANGE OR BORROW FROM EXISTING ANNUITY CONTRACTS IN CONNECTION WITH THE PURCHASE OF A NEW ANNUITY 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 CONTRACT. PLEASE REVIEW THIS DOCUMENT CAREFULLY AS IT CONTAINS IMPORTANT COMPARISON INFORMATION BETWEEN YOUR EXISTING CONTRACT AND THE NEW CONTRACT.
* IMPORTANT 60 DAY REFUND PERIOD:
IF YOU ARE NOT SATISFIED WITH YOUR NEW ANNUITY CONTRACT YOU HAVE THE RIGHT, WITHIN 60 DAYS FROM THE DATE OF DELIVERY OF YOUR 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 contract 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
|
1. DESCRIPTION OF TRANSACTION: |
AS OF DATE: |
|||
|
Proposed Annuity Contract |
Existing Annuity Contracts Affected |
|||
|
(1) |
(2) |
(3) |
||
|
__________________ |
Company |
____________ |
____________ |
_____________ |
|
_______-__________ |
Customer Service Telephone Number: |
____-_______ |
____-_______ |
____-________ |
|
__________________ |
Type of Annuity |
____________ |
____________ |
_____________ |
|
Contract Number |
# __________ |
# __________ |
# ___________ |
|
|
Issue Date |
____________ |
____________ |
_____________ |
|
|
$_________________ |
Account Value |
$___________ |
$___________ |
$____________ |
|
$_________________ |
Minus Surrender Charge |
$___________ |
$___________ |
$____________ |
|
$_________________ |
Plus/Minus Market Value Adjustment (if any) |
$___________ |
$___________ |
$____________ |
|
$_________________ |
Equals Surrender Value |
$___________ |
$___________ |
$____________ |
|
2. SUMMARY RESULT COMPARISON: |
|||||||||
|
THE PROPOSED ANNUITY |
IF YOU CONTINUE YOUR CURRENT ANNUITY |
||||||||
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Surrender Value To Be Invested: $ _________ |
Current Value $ _________ |
||||||||
|
If Variable Annuity Hypothetical Rates of Return |
If Variable Annuity Hypothetical Rates of Return |
||||||||
|
At Guaranteed Rate |
At Current Rate |
@ 0% |
@ 6% |
@ 12% |
At uaranteed Rate |
At Current Rate |
@ 0% |
@ 6% |
@ 12% |
|
SURRENDER VALUE |
|||||||||
|
$_____ |
$_____ |
$ |
$_____ |
$ ____ In 5 Yrs |
$_____ |
$_____ |
$_____ |
$_____ |
$_____ |
|
$_____ |
$_____ |
$_____ |
$_____ |
$ ____ In 10 Yrs |
$______ |
$_____ |
$_____ |
$_____ |
$_____ |
|
DEATH BENEFIT |
|||||||||
|
$_____ |
$_____ |
$_____ |
$_____ |
$ ____ In 5 Yrs |
$_____ |
$_____ |
$_____ |
$_____ |
$_____ |
|
$_____ |
$_____ |
$_____ |
$_____ |
$ ____ In 10 Yrs |
$______ |
$_____ |
$_____ |
$_____ |
$_____ |
AGENT'S OR BROKER'S STATEMENT:
1. The primary reason(s) for recommending the new annuity contract is (are):
___________________________________________________________________________
___________________________________________________________________________
2. The existing annuity contract cannot meet the applicant's objectives because:
___________________________________________________________________________
___________________________________________________________________________
3. The advantages of continuing the existing annuity contract without changes are:
___________________________________________________________________________
___________________________________________________________________________
4. The surrender charge, if my client replaces his or her existing annuity contract, is___% or $___. The new annuity my client is applying for imposes a new surrender charge as follows:
(Describe percentage rate of surrender charge for each year in which a surrender charge is imposed)
__________________________________________________________________________________________
_________________________________________________________________________________________
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 annuity contracts are to be affected by this transaction, or if more than one new annuity contract is proposed, Section 1 of this Disclosure Statement must be completed for such additional annuity contracts. In addition, a composite comparison shall be completed for all existing annuity contracts to all proposed 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.
