Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 760 WA (2005/09)
Washington Important Notice
Regarding Replacement
Use ACORD Washington Important Notice Regarding Replacement (ACORD 760 WA), to
inform the Carrier of the intent to replace a policy. The form is to be completed by the
Producer and then sent to the new Carrier.
IDENTIFICATION SECTION Company
Name and Address of Insurance
Name of Insurance Company must be inserted before this form is used. Use the actual
name of the company. Do not use group names.
IMPORTANT NOTICE
STATEMENT TO APPLICANT BY
AGENT OR BROKER
Agent/Broker must list in detail the factors indicating that the transaction will materially
improve the applicant's position.
GENERAL INFORMATION
1. Can there be reduced benefits
or increased premiums in later
years?
Answer by checking the appropriate box.
GENERAL INFORMATION
2. Are there penalties, set-up or
surrender charges for the new
policy? If yes, explain,
emphasizing any extra cost for
early withdrawal.
Answer by checking the appropriate box. If yes, explain, emphasizing any extra cost for
early withdrawal.
GENERAL INFORMATION
3. Will there be penalties or
surrender charges under the
existing insurance as a result of
the proposed transaction?
Answer by checking the appropriate box.
GENERAL INFORMATION
4. Are there adverse tax
consequences for the replacement
under current tax law?
Answer by checking the appropriate box.
GENERAL INFORMATION
5a. Are interest earnings a
consideration in this replacement?
Answer by checking the appropriate box.
ACORD 760 WA (2005/09)
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Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 760 WA (2005/09)
Washington Important Notice
Regarding Replacement
Use ACORD Washington Important Notice Regarding Replacement (ACORD 760 WA), to
inform the Carrier of the intent to replace a policy. The form is to be completed by the
Producer and then sent to the new Carrier.
GENERAL INFORMATION
5b. If yes, explain what portions of
premiums or contributions will
produce limited or no earnings.
As pertinent, include in your
explanation the need for minimum
deposits to enhance earnings, and
the reduction of earnings that may
result from set-up charges, policy
fees, and other factors.
If yes, explain what portions of premiums or contributions will produce limited or no
earnings. As pertinent, include in your explanation the need for minimum deposits to
enhance earnings, and the reduction of earnings that may result from set-up charges,
policy fees, and other factors.
GENERAL INFORMATION
6. Are minimum amounts required
to be on deposit before excess
interest will be paid?
Answer by checking the appropriate box.
GENERAL INFORMATION
7. If the new program is based on
a variable or universal life
insurance policy or a single-
premium policy or annuity:
GENERAL INFORMATION
a) Are the interest rates quoted
before or after fees and mortality
charges have been deducted?
Answer by checking the appropriate box.
GENERAL INFORMATION
b) Interest rates are guaranteed
for how long?
Indicate how long the interest rates are guaranteed for.
GENERAL INFORMATION
c) The minimum interest rate to be
paid is how much?
Indicate the minimum interest rate to be paid.
GENERAL INFORMATION
d) If applicable, the rate you pay
to borrow is
Indicate the rate the applicant will have to pay to borrow, if applicable.
GENERAL INFORMATION
d) and the limit on the amount that
can be borrowed is
Indicate the limit on the amount that can be borrowed, if applicable.
GENERAL INFORMATION
e) The surrender charges are
Indicate the surrender charges, if any.
GENERAL INFORMATION
f) The death benefit is
Indicate what the death benefit is.
ACORD 760 WA (2005/09)
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Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 760 WA (2005/09)
Washington Important Notice
Regarding Replacement
Use ACORD Washington Important Notice Regarding Replacement (ACORD 760 WA), to
inform the Carrier of the intent to replace a policy. The form is to be completed by the
Producer and then sent to the new Carrier.
GENERAL INFORMATION
8. Are there any other short or
long term effects from the
replacement that might be
materially adverse?
Answer by checking the appropriate box.
PRODUCER SIGNATURE
Signature of Agent
Producer must sign the form.
PRODUCER SIGNATURE
Date
Date the producer signed the form.
PRODUCER SIGNATURE
Name of Agent
Type or print name of producer.
PRODUCER SIGNATURE
Address
Address of the Producer.
LIST OF POLICIES TO BE
REPLACED
Insurer Name
Indicate the name of the insurer of the existing policy or contract that is being considered
for replacement.
LIST OF POLICIES TO BE
REPLACED
Insured or Annuitant
Indicate the name of the insured or annuitant of the existing policy or contract that is being
considered for replacement.
LIST OF POLICIES TO BE
REPLACED
Contract or Policy #
Indicate the contract or policy number of the existing policy or contract that is being
considered for replacement.
APPLICANT SIGNATURE
Completed Copy Received
Check this box if Applicant received a completed copy of the Replacement Form.
APPLICANT SIGNATURE
Signature of Applicant
Applicant must sign the form.
APPLICANT SIGNATURE
Date
Date the applicant signed the form.
REMARKS
Use this space for any additional comments or remarks.
ACORD 760 WA (2005/09)
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