<html> <head> <title>Rule 20:06:21:0J Replacement and Lapse Reporting Form.</title> <META NAME="Keywords" Content="Administrative Rules 20:06:21:0J"> <META NAME="Description" Content="Administrative Rules 20:06:21:0J Replacement and Lapse Reporting Form."> <meta http-equiv=Content-Type content="text/html; charset=windows-1252"> <meta name=Generator content="Microsoft Word 14 (filtered)"> <title>DEPARTMENT OF REVENUE AND REGULATION</title> <style> <!-- /* Font Definitions */ @font-face {font-family:Times; panose-1:2 2 6 3 5 4 5 2 3 4;} /* Style Definitions */ p.MsoNormal, li.MsoNormal, div.MsoNormal {margin:0in; margin-bottom:.0001pt; font-size:10.0pt; font-family:"Times","serif";} h1 {margin:0in; margin-bottom:.0001pt; text-align:center; page-break-after:avoid; font-size:12.0pt; font-family:"Times New Roman","serif"; font-weight:normal;} h2 {margin:0in; margin-bottom:.0001pt; text-align:center; page-break-after:avoid; font-size:14.0pt; font-family:"Times New Roman","serif";} h3 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style='font-size: 12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size: 12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size: 12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size: 12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size: 12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size: 12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size: 12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size: 12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size: 12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size: 12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>DEPARTMENT OF LABOR AND REGULATION</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>DIVISION OF INSURANCE</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>REPLACEMENT AND LAPSE REPORTING FORM</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>Chapter 20:06:21</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>APPENDIX J</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>SEE: &#167;</span></font><font size=3><span style='font-size:12.0pt'> </span></font><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>20:06:21:52</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b><span style='font-weight:bold'>Source:</span></b> 28 SDR 157, effective May 19, 2002.</span></font></p> <b><font size=3 face="Times New Roman"><span style='font-size:12.0pt; font-family:"Times New Roman","serif";font-weight:bold'><br clear=all style='page-break-before:always'> </span></font></b> <p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size: 12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><b><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"; font-weight:bold'>Long-Term Care Insurance</span></font></b></p> <p class=MsoNormal align=center style='text-align:center'><b><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"; font-weight:bold'>Replacement and Lapse Reporting Form</span></font></b></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal><i><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif";font-style:italic'>For the State of</span></font></i><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'> _____________________&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<i><span style='font-style: italic'>For the Reporting Year of</span></i> __________</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size: 12.0pt;font-family:"Times New Roman","serif"'>Company Name:&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; __________________________&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Due:&nbsp;&nbsp; June 30 annually</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>Company Address:&nbsp; __________________________&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Company NAIC Number: _________</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>Contact Person:&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; __________________________&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Phone Number:&nbsp; (____)___________</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>Instructions</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoBodyText style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:11.5pt;font-family:"Times New Roman","serif"; text-decoration:none'>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 percentage of replacements and lapses.</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:11.5pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal style='text-align:justify'><b><font size=3 face="Times New Roman"><span style='font-size:11.5pt;font-family:"Times New Roman","serif"; font-weight:bold'>Listing of the 10% of Agents with the Greatest Percentage of Replacements</span></font></b></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:11.5pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <table class=MsoNormalTable border=1 cellspacing=0 cellpadding=0 style='margin-left:5.4pt;border-collapse:collapse;border:none'> <tr> <td width=102 valign=top style='width:76.5pt;border:solid windowtext 1.0pt; border-bottom:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:11.5pt;font-family:"Times New Roman","serif"'>Agent's Name</span></font></p> </td> <td width=168 valign=top style='width:1.75in;border-top:solid windowtext 1.0pt; border-left:none;border-bottom:none;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:11.5pt;font-family:"Times New Roman","serif"'>Number of Policies Sold</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:11.5pt;font-family:"Times New Roman","serif"'>By This Agent</span></font></p> </td> <td width=168 valign=top style='width:1.75in;border-top:solid windowtext 1.0pt; border-left:none;border-bottom:none;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:11.5pt;font-family:"Times New Roman","serif"'>Number of Policies</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:11.5pt;font-family:"Times New Roman","serif"'>Replaced by This Agent</span></font></p> </td> <td width=210 valign=top style='width:157.5pt;border-top:solid windowtext 1.0pt; border-left:none;border-bottom:none;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:11.5pt;font-family:"Times New Roman","serif"'>Number of Replacements As % of Number Sold By This Agent</span></font></p> </td> </tr> <tr> <td width=102 valign=top style='width:76.5pt;border:solid windowtext 1.0pt; border-bottom:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> <td width=168 valign=top style='width:1.75in;border-top:solid windowtext 1.0pt; border-left:none;border-bottom:none;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> <td width=168 valign=top style='width:1.75in;border-top:solid windowtext 1.0pt; border-left:none;border-bottom:none;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> <td width=210 valign=top style='width:157.5pt;border-top:solid windowtext 1.0pt; border-left:none;border-bottom:none;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> </tr> <tr> <td width=102 valign=top style='width:76.5pt;border-top:none;border-left: solid windowtext 1.0pt;border-bottom:none;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> <td width=168 valign=top style='width:1.75in;border:none;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> <td width=168 valign=top style='width:1.75in;border:none;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> <td width=210 valign=top style='width:157.5pt;border:none;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> </tr> <tr> <td width=102 valign=top style='width:76.5pt;border-top:none;border-left: solid windowtext 1.0pt;border-bottom:none;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> <td width=168 valign=top style='width:1.75in;border:none;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> <td width=168 valign=top style='width:1.75in;border:none;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> <td width=210 valign=top style='width:157.5pt;border:none;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> </tr> <tr> <td width=102 valign=top style='width:76.5pt;border-top:none;border-left: solid windowtext 1.0pt;border-bottom:none;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> <td width=168 valign=top style='width:1.75in;border:none;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> <td width=168 valign=top style='width:1.75in;border:none;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> <td width=210 valign=top style='width:157.5pt;border:none;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> </tr> <tr> <td width=102 valign=top style='width:76.5pt;border:solid windowtext 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> <td width=168 valign=top style='width:1.75in;border-top:none;border-left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> <td width=168 valign=top style='width:1.75in;border-top:none;border-left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> <td width=210 valign=top style='width:157.5pt;border-top:none;border-left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> </tr> </table> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:11.5pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal><b><font size=3 face="Times New Roman"><span style='font-size:11.5pt;font-family:"Times New Roman","serif";font-weight:bold'>Listing of the 10% of Agents with the Greatest Percentage of Lapses</span></font></b></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:11.5pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <table class=MsoNormalTable border=1 cellspacing=0 cellpadding=0 style='margin-left:5.4pt;border-collapse:collapse;border:none'> <tr> <td width=102 valign=top style='width:76.5pt;border:solid windowtext 1.0pt; border-bottom:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:11.5pt;font-family:"Times New Roman","serif"'>Agent's Name</span></font></p> </td> <td width=168 valign=top style='width:1.75in;border-top:solid windowtext 1.0pt; border-left:none;border-bottom:none;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:11.5pt;font-family:"Times New Roman","serif"'>Number of Policies Sold</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:11.5pt;font-family:"Times New Roman","serif"'>By This Agent</span></font></p> </td> <td width=168 valign=top style='width:1.75in;border-top:solid windowtext 1.0pt; border-left:none;border-bottom:none;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:11.5pt;font-family:"Times New Roman","serif"'>Number of Policies</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:11.5pt;font-family:"Times New Roman","serif"'>Lapsed By This Agent</span></font></p> </td> <td width=210 valign=top style='width:157.5pt;border-top:solid windowtext 1.0pt; border-left:none;border-bottom:none;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:11.5pt;font-family:"Times New Roman","serif"'>Number of Lapses As % of Number Sold By This Agent</span></font></p> </td> </tr> <tr> <td width=102 valign=top style='width:76.5pt;border:solid windowtext 1.0pt; border-bottom:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> <td width=168 valign=top style='width:1.75in;border-top:solid windowtext 1.0pt; border-left:none;border-bottom:none;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> <td width=168 valign=top style='width:1.75in;border-top:solid windowtext 1.0pt; border-left:none;border-bottom:none;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> <td width=210 valign=top style='width:157.5pt;border-top:solid windowtext 1.0pt; border-left:none;border-bottom:none;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> </tr> <tr> <td width=102 valign=top style='width:76.5pt;border-top:none;border-left: solid windowtext 1.0pt;border-bottom:none;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> <td width=168 valign=top style='width:1.75in;border:none;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> <td width=168 valign=top style='width:1.75in;border:none;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> <td width=210 valign=top style='width:157.5pt;border:none;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> </tr> <tr> <td width=102 valign=top style='width:76.5pt;border-top:none;border-left: solid windowtext 1.0pt;border-bottom:none;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> <td width=168 valign=top style='width:1.75in;border:none;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> <td width=168 valign=top style='width:1.75in;border:none;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> <td width=210 valign=top style='width:157.5pt;border:none;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> </tr> <tr> <td width=102 valign=top style='width:76.5pt;border-top:none;border-left: solid windowtext 1.0pt;border-bottom:none;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> <td width=168 valign=top style='width:1.75in;border:none;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> <td width=168 valign=top style='width:1.75in;border:none;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> <td width=210 valign=top style='width:157.5pt;border:none;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> </tr> <tr> <td width=102 valign=top style='width:76.5pt;border:solid windowtext 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> <td width=168 valign=top style='width:1.75in;border-top:none;border-left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> <td width=168 valign=top style='width:1.75in;border-top:none;border-left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> <td width=210 valign=top style='width:157.5pt;border-top:none;border-left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </td> </tr> </table> <p class=MsoNormal style='text-align:justify'><font size=2 face="Times New Roman"><span style='font-size:11.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal><font size=2 face="Times New Roman"><span style='font-size: 11.0pt;font-family:"Times New Roman","serif"'>Company Totals</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=2 face="Times New Roman"><span style='font-size:11.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal><font size=2 face="Times New Roman"><span style='font-size: 11.0pt;font-family:"Times New Roman","serif"'>Percentage of Replacement Policies Sold to Total Annual Sales _____%</span></font></p> <p class=MsoBodyText style='text-align:justify'><font size=2 face="Times New Roman"><span style='font-size:11.0pt;font-family:"Times New Roman","serif"; text-decoration:none'>Percentage of Replacement Policies Sold to Policies in Force (as of the end of the preceding calendar year) _____%</span></font></p> <p class=MsoBodyText style='text-align:justify'><font size=2 face="Times New Roman"><span style='font-size:11.0pt;font-family:"Times New Roman","serif"; text-decoration:none'>&nbsp;</span></font></p> <p class=MsoBodyText style='text-align:justify'><font size=2 face="Times New Roman"><span style='font-size:11.0pt;font-family:"Times New Roman","serif"; text-decoration:none'>Percentage of Lapsed Policies to Total Annual Sales _____%</span></font></p> <p class=MsoBodyText style='text-align:justify'><font size=2 face="Times New Roman"><span style='font-size:11.0pt;font-family:"Times New Roman","serif"; text-decoration:none'>Percentage of Lapsed Policies to Policies In Force (as of the end of the preceding calendar year) _____%</span></font></p> <p class=MsoBodyText><font size=2 face="Times New Roman"><span style='font-size:11.0pt;font-family:"Times New Roman","serif";text-decoration: none'>&nbsp;</span></font></p> <p class=MsoNormal><font size=2 face="Times New Roman"><span style='font-size: 10.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> </div> </body> </html>