The Life Underwriting Guide - Pilot Insurance Center

REPLACEMENT FORMS (Nebraska to Wyoming)
The E-Replacement Questionnaire (EREPL) is required in all states except New York.
The NAIC E-Replacement Disclosure Notice (EREPLDIS-NAIC) is required in the NAIC states
only (shown in Navy Blue).
The E-Replacement Sales Material Disclosure Form (EREPLSMDIS) is required in the NAIC states.
The E-Replacement Disclosure Notice (EREPLDIS-XX, state-specific or generic) is required in
all non-NAIC states, and the few states (shown in Brown) where no state form is required.
STATE EREPL EREPLDIS-NAIC EREPLSMDIS EREPLDIS-XX
Nebraska Required Required Required
Nevada Required EREPLDIS-NV
New
Hampshire
Required Required Required
New Jersey Required Required Required
New Mexico Required Required Required
EREPLDIS-NY-A
EREPLDIS-NY-B
New York > > > > >
EREPLDIS-NY-C
EREPLDIS-NY-D
EREPLDIS-NY-DEF
North Carolina Required Required Required
North Dakota Required EREPLDIS
Ohio Required Required Required
Oklahoma Required EREPLDIS-OK
Oregon Required Required Required
Pennsylvania Required EREPLDIS-PA
Puerto Rico Required EREPLDIS-PR
Rhode Island Required Required Required
South Carolina Required EREPLDIS-SC
South Dakota Required EREPLDIS-SD
Tennessee Required EREPLDIS-TN
Texas Required Required Required
Utah Required Required Required
Vermont Required Required Required
Virginia Required Required Required
Washington Required EREPLDIS-WA
West Virginia Required Required Required
Wisconsin Required EREPLDIS-WI
Wyoming Required EREPLDIS-WY
FOR FINANCIAL PROFESSIONAL USE ONLY --- NOT FOR PUBLIC DISTRIBUTION
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