Wisconsin Administrative Code
Office of the Commissioner of Insurance
Chapter Ins 3 - Casualty Insurance
Appendix 10

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: ______________________________________________

Phone 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 percent of the agent's total annual sales and the amount of lapses of long-term care insurance policies sold by the agent as a percent 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

Listing of the 10% of Agents with the Greatest Percentage of Lapses

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) ____%