Okla. Stat. tit. 36, § 36-4036: Statement by applicant regarding notification of

replacement to replaced insurer.

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. The legal name

and address of the replacing insurer may be printed on the

statement. Said statement shall be in substance as follows:

STATEMENT BY APPLICANT REGARDING NOTIFICATION

OF REPLACEMENT TO THE REPLACED INSURER

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.)

1. Please notify my present insurer(s) regarding this

transaction.

_______________________

_______________________

_

Date Signature of Applicant

2. Please do not notify my present insurer(s) regarding this

transaction.

_______________________ ________________________

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

__________________________

Insurance Agency or Agent

License Number