Section 2012.EXHIBIT K Replacement and Lapse Reporting Form

Long-Term Care Insurance

Replacement and Lapse Reporting Form

For the State of
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 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 % 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 Lapsed By This Agent	Number of Lapses As % 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)		%
		%

(Source: Added at 32 Ill. Reg. 7600, effective May 5, 2008)