North Dakota Administrative Code
Title 45 - Insurance, Commissioner of
Article 45-06 - Accident and Health Insurance
Chapter 45-06-05.1 - LONG-TERM CARE INSURANCE MODEL REGULATION
Appendix G - Replacement and Lapse Reporting Form
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: ___________________ Telephone 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 agent on that agent's amount of long-term care insurance replacement sales as a percentage of the agent's total annual sales and the amount of lapses of long-term care insurance policies sold by the agent as a percentage of the agent's total annual sales. The tables below should be used to report the ten percent (10%) of the insurer's agents with the greatest percentages of replacements and lapses.
Listing of the 10% of Agents With the Greatest Percentage of Replacements
| Agent's Name | Number of Policies Sold by This Agent | Number of Policies Replaced by This Agent | Number of Replacements as Percentage of Number Sold by This Agent |
Listing of the 10% of Agents With the Greatest Percentage of Lapses
| Agent's Name | Number of Policies Sold by This Agent | Number of Policies Replaced by This Agent | Number of Replacements as Percentage of Number Sold by This Agent |
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) _____%
