Section Name |
Field Name |
Field and/or Section Description |
|
Texas Important Notice: |
Use ACORD 759 TX, Texas Important Notice: Replacement of Life Insuranceor |
TITLE |
Replacement of Life Insurance or |
Annuities, in the state of Texas, to inform the Carrier of the intent to replace a policy. The |
ACORD 759 TX (2008/02) |
Annuities |
form is to be completed by the Producer and then sent to the new Carrier. |
|
Name and Address of Insurance |
Name of Insurance Company must be inserted before this form is used. Use the actual |
IDENTIFICATION SECTION |
Company |
name of the company. Do not use group names. |
REPLACEMENT OF LIFE INSURANCE OR ANNUITIES |
1. Are you considering discontinuing making premium payments, surrendering, forfeiting, assigning to the insurer, or otherwise terminating your existing policy or contract? |
Answer by checking the appropriate box. |
REPLACEMENT OF LIFE INSURANCE OR ANNUITIES |
2. Are you considering using funds from your existing policies or contracts to pay premiums due on the new policy or contract? |
Answer by checking the appropriate box. |
REPLACEMENT OF LIFE |
|
Indicate the name of the insurer of the existing policy or contract that is being considered |
INSURANCE OR ANNUITIES |
Insurer Name |
for replacement. |
REPLACEMENT OF LIFE |
|
Indicate the contract or policy number of the existing policy or contract that is being |
INSURANCE OR ANNUITIES |
Contract or Policy # |
considered for replacement. |
REPLACEMENT OF LIFE |
|
Indicate the name of the insured or annuitant of the existing policy or contract that is being |
INSURANCE OR ANNUITIES |
Insured or Annuitant |
considered for replacement. |
REPLACEMENT OF LIFE |
|
|
INSURANCE OR ANNUITIES |
Replaced /Financed |
Indicate whether each policy or contract will be replaced or used as a source of financing. |
REPLACEMENT OF LIFE |
The Existing Policy or Contract is |
|
INSURANCE OR ANNUITIES |
Being Replaced Because: |
Indicate the reason you are contemplating replacing your current policy or contract. |
APPLICANT’S |
|
|
CERTIFICATION |
Applicant’s Signature |
Applicant must sign the form. |
|
Texas Important Notice: |
Use ACORD 759 TX, Texas Important Notice: Replacement of Life Insurance or |
TITLE |
Replacement of Life Insurance or |
Annuities, in the state of Texas, to inform the Carrier of the intent to replace a policy. The |
ACORD 759 TX (2008/02) |
Annuities |
form is to be completed by the Producer and then sent to the new Carrier. |
APPLICANT’S |
|
|
CERTIFICATION |
Printed Name |
Print or type the full name of the applicant. |
APPLICANT’S |
|
|
CERTIFICATION |
Date |
Date the applicant signed the form (mm/dd/yyyy). |
PRODUCER’S |
|
|
CERTIFICATION |
Producer’s Signature |
Producer must sign the form. |
PRODUCER’S |
|
|
CERTIFICATION |
Printed Name |
Print or type the full name of the producer. |
PRODUCER’S |
|
|
CERTIFICATION |
Date |
Date the producer signed the form (mm/dd/yyyy). |
APPLICANT’S |
|
|
CERTIFICATION |
Applicant’s Initials |
Applicant must initial the form if they do not want the notice read aloud to them. |