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

Current through Register Vol. 46, No. 28, July 10, 2024
DISCLOSURE STATEMENT (Annuity-to-Annuity Replacement
				Only)
IMPORTANT
- IT MAY
NOT
BE IN YOUR BEST INTEREST TO SURRENDER, LAPSE,
				CHANGE OR BORROW FROM EXISTING ANNUITY CONTRACTS IN CONNECTION WITH THE
				PURCHASE OF A NEW ANNUITY 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 CONTRACT. PLEASE REVIEW THIS
				DOCUMENT CAREFULLY AS IT CONTAINS IMPORTANT COMPARISON INFORMATION BETWEEN YOUR
				EXISTING CONTRACT AND THE NEW CONTRACT.
* IMPORTANT 60 DAY REFUND PERIOD:
IF YOU ARE NOT SATISFIED WITH YOUR NEW ANNUITY CONTRACT
				YOU HAVE THE RIGHT, WITHIN 60 DAYS FROM THE DATE OF DELIVERY OF YOUR 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 contract 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 Annuity Contract
Existing Annuity Contracts Affected
(1)
(2)
(3)
__________________
Company
____________
____________
_____________
_______-__________
Customer Service Telephone Number:
____-_______
____-_______
____-________
__________________
Type of Annuity
____________
____________
_____________
Contract Number
# __________
# __________
# ___________
Issue Date
____________
____________
_____________
$_________________
Account Value
$___________
$___________
$____________
$_________________
Minus Surrender Charge
$___________
$___________
$____________
$_________________
Plus/Minus Market Value Adjustment (if any)
$___________
$___________
$____________
$_________________
Equals Surrender Value
$___________
$___________
$____________
2.
SUMMARY RESULT COMPARISON:
THE PROPOSED ANNUITY
IF YOU CONTINUE YOUR CURRENT
						  ANNUITY
Surrender Value To Be Invested: $
						  _________
Current Value $ _________
If Variable Annuity Hypothetical Rates of Return
If Variable Annuity Hypothetical Rates of Return
At Guaranteed Rate
At Current Rate
@ 0%
@ 6%
@ 12%
At uaranteed Rate
At Current Rate
@ 0%
@ 6%
@ 12%
SURRENDER VALUE
$_____
$_____
$
$_____
$ ____ In 5 Yrs
$_____
$_____
$_____
$_____
$_____
$_____
$_____
$_____
$_____
$ ____ In 10 Yrs
$______
$_____
$_____
$_____
$_____
DEATH BENEFIT
$_____
$_____
$_____
$_____
$ ____ In 5 Yrs
$_____
$_____
$_____
$_____
$_____
$_____
$_____
$_____
$_____
$ ____ In 10 Yrs
$______
$_____
$_____
$_____
$_____
AGENT'S OR BROKER'S STATEMENT:
1. The primary reason(s) for recommending the new annuity
				contract is (are):
___________________________________________________________________________
___________________________________________________________________________
2. The existing annuity contract cannot meet the applicant's
				objectives because:
___________________________________________________________________________
___________________________________________________________________________
3. The advantages of continuing the existing annuity contract
				without changes are:
___________________________________________________________________________
___________________________________________________________________________
4. The surrender charge, if my client replaces his or her
				existing annuity contract, is___% or $___. The new annuity my client is
				applying for imposes a new surrender charge as follows:
(Describe percentage rate of surrender charge for each year in
				which a surrender charge is imposed)
__________________________________________________________________________________________
_________________________________________________________________________________________
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 annuity contracts are to be
				affected by this transaction, or if more than one new annuity contract is
				proposed, Section 1 of this Disclosure Statement must be completed for such
				additional annuity contracts. In addition, a composite comparison shall be
				completed for all existing annuity contracts to all proposed 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.