| 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. |