© 2007 National Association of Insurance Commissioners
Model Regulation Service—October 2007
APPENDIX A
IMPORTANT NOTICE:
REPLACEMENT OF LIFE INSURANCE OR ANNUITIES
This document must be signed by the applicant and the producer, if there is one,
and a copy left with the applicant.
You are contemplating the purchase of a life insurance policy or annuity contract. In some cases this purchase
may involve discontinuing or changing an existing policy or contract. If so, a replacement is occurring. Financed
purchases are also considered replacements.
A replacement occurs when a new policy or contract is purchased and, in connection with the sale, you
discontinue making premium payments on the existing policy or contract, or an existing policy or contract is
surrendered, forfeited, assigned to the replacing insurer, or otherwise terminated or used in a financed
purchase.
A financed purchase occurs when the purchase of a new life insurance policy involves the use of funds obtained
by the withdrawal or surrender of or by borrowing some or all of the policy values, including accumulated
dividends, of an existing policy to pay all or part of any premium or payment due on the new policy. A financed
purchase is a replacement.
You should carefully consider whether a replacement is in your best interests. You will pay acquisition costs and
there may be surrender costs deducted from your policy or contract. You may be able to make changes to your
existing policy or contract to meet your insurance needs at less cost. A financed purchase will reduce the value
of your existing policy and may reduce the amount paid upon the death of the insured.
We want you to understand the effects of replacements before you make your purchase decision and ask that
you answer the following questions and consider the questions on the back of this form.
1. Are you considering discontinuing making premium payments, surrendering, forfeiting, assigning to
the insurer, or otherwise terminating your existing policy or contract? ___ YES ___ NO
2. Are you considering using funds from your existing policies or contracts to pay premiums due on the
new policy or contract? ___ YES ___ NO
If you answered “yes” to either of the above questions, list each existing policy or contract you are
contemplating replacing (include the name of the insurer, the insured or annuitant, and the policy or
contract number if available) and whether each policy or contract will be replaced or used as a source of
financing:
INSURER
NAME
CONTRACT OR
POLICY #
INSURED OR
ANNUITANT
REPLACED (R) OR
FINANCING (F)
1.
2.
3.
Make sure you know the facts. Contact your existing company or its agent for information about the old
policy or contract. If you request one, an in force illustration, policy summary or available disclosure
documents must be sent to you by the existing insurer. Ask for and retain all sales material used by the
agent in the sales presentation. Be sure that you are making an informed decision.
The existing policy or contract is being replaced because ___________________________________________________.
I certify that the responses herein are, to the best of my knowledge, accurate:
________________________________________________________________ __________________________
Applicant’s Signature and Printed Name Date
________________________________________________________________ __________________________
Producer’s Signature and Printed Name Date
I do not want this notice read aloud to me. ____ (Applicants must initial only if they do not want the notice read
aloud.)