New York Codes, Rules and Regulations › Title 11 - INSURANCE › Appendices › Appendix 10A - DEPARTMENT OF FINANCIAL SERVICES OF THE STATE OF NEW YORK

Current through Register Vol. 46, No. 28, July 10, 2024
DISCLOSURE STATEMENT
IMPORTANT
- IT MAY NOT BE IN
				YOUR BEST INTEREST TO SURRENDER, LAPSE, CHANGE OR BORROW FROM EXISTING LIFE
				INSURANCE POLICIES OR ANNUITY CONTRACTS IN CONNECTION WITH THE PURCHASE OF A
				NEW POLICY OR CONTRACT WHETHER ISSUED BY THE SAME OR A DIFFERENT INSURANCE
				COMPANY
* THIS DISCLOSURE STATEMENT IS REQUIRED TO BE PROVIDED TO
				YOU NO LATER THAN UPON DELIVERY OF THE NEW POLICY OR CONTRACT. PLEASE REVIEW
				THIS DOCUMENT CAREFULLY AS IT CONTAINS IMPORTANT COMPARISON INFORMATION BETWEEN
				YOUR EXISTING INSURANCE POLICY OR ANNUITY CONTRACT AND THE NEW POLICY OR
				CONTRACT.
* IMPORTANT 60 DAY REFUND PERIOD:
IF YOU ARE NOT SATISFIED WITH YOUR NEW LIFE INSURANCE
				POLICY OR ANNUITY CONTRACT YOU HAVE THE RIGHT, WITHIN 60 DAYS FROM THE DATE OF
				DELIVERY OF YOUR POLICY OR CONTRACT, TO RETURN IT AND RECEIVE A
				REFUND.
* PLEASE CONTACT THE COMPANY, AGENT OR BROKER IF YOU HAVE
				ANY QUESTIONS.
FOR YOUR PROTECTION,
the Department of Financial
				Services of the State of New York requires that you be given this Disclosure
				Statement with policy information on all proposed and existing coverage
				affected.
Name of Applicant______________________________Telephone#
				________________
Address_________________________________________________________________________
Name of Agent or Broker_________________________Telephone
				#_________________________
Company______________________________________Address___________________________
The information on existing coverage on this form was obtained
				from
____the replaced company
____approximations if replaced company failed to provide
				information in the prescribed time
1.
DESCRIPTION OF TRANSACTION
:
AS OF DATE
:
Proposed Policy/Contract
Existing Policies/Contracts Affected
(1)
(2)
(3)
____________
Company
____________
____________
____________
_______-__________
Customer Service Telephone Number
:____-_______
____-_______
____-_______
____________
Type of Insurance
____________
____________
____________
$___________
Face Amount
$___________
$___________
$___________
$___________
Rider _________
$___________
$___________
$___________
$___________
Rider _________
$___________
$___________
$___________
$___________
Rider _________
$___________
$___________
$___________
$___________
Rider _________
$___________
$___________
$___________
$___________
Rider _________
$___________
$___________
$___________
$___________
Premium
$___________
$___________
$___________
Contract Number
# __________
# __________
# __________
Issue Date
____________
____________
____________
$__________
Surrender Charge
$___________
$___________
$___________
__________ %
Guaranteed Interest Rate
__________ %
__________ %
__________ %
__________ %
Loan Interest Rate
__________ %
__________ %
__________ %
__________ Years
Contestable Expiry Date
________ M/Y
________ M/Y
________ M/Y
__________ Years
Suicide Expiry Date
________ M/Y
________ M/Y
________ M/Y
Existing coverage to be changed by:
Lapse or Surrender
[ ]
[ ]
[ ]
Amendment or Reissue
[ ]
[ ]
[ ]
Loan or Withdrawal
[ ]
[ ]
[ ]
Reduction To
$___________
$___________
$___________
Reduced Paid-Up For
$___________
$___________
$___________
Extended Term For
___Yrs___Mos
___Yrs___Mos
___Yrs___Mos
Cash released by change
Year _________
$___________
$___________
$___________
Year _________
$___________
$___________
$___________
Year _________
$___________
$___________
$___________
Use of cash
				released:____________________________________________________________________________
2. SUMMARY RESULT COMPARISON:
New With Existing Coverage Changed
Existing Coverage Unchanged
Guaranteed
Non-Guaranteed
Annual Premium
Guaranteed
Non-Guaranteed
$__________
$__________
At Present
$__________
$__________
$__________
$__________
5 Years Hence
$__________
$__________
$__________
$__________
10 Years Hence
$__________
$__________
Guaranteed
Non-Guaranteed
Surrender Value
Guaranteed
Non-Guaranteed
$__________
$__________
At Present
$__________
$__________
$__________
$__________
5 Years Hence
$__________
$__________
$__________
$__________
10 Years Hence
$__________
$__________
Guaranteed
Non-Guaranteed
Death Benefit
Guaranteed
Non-Guaranteed
$__________
$__________
At Present
$__________
$__________
$__________
$__________
5 Years Hence
$__________
$__________
$__________
$__________
10 Years Hence
$__________
$__________
Guaranteed
Non-Guaranteed
Dividends
Guaranteed
Non-Guaranteed
$__________
$__________
At Present
$__________
$__________
$__________
$__________
5 Years Hence
$__________
$__________
$__________
$__________
10 Years Hence
$__________
$__________
AGENT'S OR BROKER'S STATEMENT:
1. The primary reason(s) for recommending the new life
				insurance policy or annuity contract is (are):
______________________________________________________________________________
______________________________________________________________________________
2. The existing life insurance policy or annuity contract
				cannot meet the applicant's objectives because:
______________________________________________________________________________
______________________________________________________________________________
3. The advantages of continuing the existing life insurance
				policy or annuity contract without changes are:
______________________________________________________________________________
______________________________________________________________________________
REMARKS
:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
[] Sales material, including proposal, was used in this
				sale.
[] No sales material or proposal was used in this sale.
If more than three existing life insurance policies or annuity
				contracts are to be affected by this transaction, or if more than one new life
				insurance policy or annuity contract is proposed, Section 1 of this Disclosure
				Statement must be completed for such additional life insurance policies and
				annuity contracts. In addition, a composite comparison shall be completed for
				all existing life insurance policies or annuity contracts to all proposed life
				insurance policies or annuity contracts. Sales material, including any proposal
				used, has been provided to the insurer. Copies of the sales material and any
				proposal have also been given to the applicant.
I have personally completed this form and certify that it
				is correct to the best of my knowledge and ability.
Date: ____________________________ Signature of Agent or
				Broker: ___________________
*** Applicant Acknowledgement
I hereby acknowledge that I received and read the above
				"Disclosure Statement."
Date: ____________________________ Signature of
				Applicant: _______________________
Date: ____________________________ Signature of
				Applicant: _______________________
***
Applicant Acknowledgment may be included or
				omitted at insurer's option.