The statement referred to in the Life Insurance and Annuity Policyholders Protection Act shall be delivered to the applicant for a replacement life insurance policy or a replacement annuity policy along with the notice provided for in Section 5 of the Life Insurance and Annuity Policyholders Protection Act.¹ The legal name and address of the replacing insurer may be printed on the statement. Said statement shall be in substance as follows:

I have read the “NOTICE TO APPLICANTS REGARDING REPLACEMENT OF LIFE INSURANCE OR AN ANNUITY” which was furnished to me by the agent taking the application for this policy.

(Applicant: Please sign ONE of the following statements.)

__________________Date______________________Signature of Applicant

The signature of the applicant shall be that of the insured unless someone other than the insured is the owner of the policy. If someone other than the insured is the owner of the policy, the owner must sign. If the insured is under eighteen (18) years of age, the parent is deemed to be the owner of the policy.

Certification by the agent:

I hereby certify that nothing was said or done during the sales presentation to influence the decision of the applicant regarding this statement.

__________________Date______________________Signature of Agent

License Number