DEPARTMENT
OF LABOR AND REGULATION
DIVISION
OF INSURANCE
PERSONAL
WORKSHEET
Chapter
20:06:21
APPENDIX
E
SEE:
§ 20:06:21:53.02
Source: 28 SDR 157, effective May 19, 2002.
Long-Term Care Insurance
Personal
Worksheet
People
buy long-term care insurance for many reasons. Some don't want to use their own
assets to pay for long-term care. Some buy insurance to make sure they can
choose the type of care they get. Others don't want their family to have to pay
for care or don't want to go on Medicaid. But long-term care insurance may be
expensive, and may not be right for everyone.
By
state law, the insurance company must fill out part of the information on this
worksheet and ask you fill out the
rest to help you and the company decide if you should buy this policy.
Premium Information
Policy
Form Numbers _____________________________
The
premium for the coverage you are considering will be [$ ________ per month, or
$ ________ per year,] [a one-time single premium of $ __________.]
Type of Policy (noncancellable
/ guaranteed renewable):
______________________________________________
The Company's Right to Increase Premiums:
___________________________________________
[The
company cannot raise your rates on this policy.] [The company has a right to
increase premiums on this policy form in the future, provided it raises rates
for all policies in the same class in this state.] [Insurers shall use
appropriate bracketed statement. Rate guarantees shall not be shown on this
form.]
Rate
Increase History
The
company has sold long-term care insurance since [year] and has sold this policy
since [year]. [The company has never raised its rates for any long-term care
policy it has sold in this state or any other state.] [The company has not
raised its rates for this policy form or similar policy forms in this state or
any other state in the last 10 years.] [The company has raised its premium
rates on this policy form or similar policy forms in the last 10 years.
Following is a summary of the rate increases.]
Questions
Related to Your Income
How
will you pay each year's premium?
□
From my Income □
From my Savings/Investments □
My Family will Pay
[□
Have you considered whether you could afford to keep this policy if the
premiums went up, for example, by 20%?]
What is your annual income? (check one) □ Under $10,000 □ $[10-20,000] □ $[20-30,000] □ $[30-50,000] □ Over $50,000
How
do you expect your income to change over the next 10 years? (check one)
□
No change □
Increase □
Decrease
If you will be paying premiums with money received
only from your own income, a rule of thumb is that you may not be able to
afford this policy if the premiums will be more than 7% of your income.
Will you buy inflation protection?
(check one) □
Yes □
No
If
not, have you considered how you will pay for the difference between future
costs and your daily benefit amount? □
From my Income □
From my Savings/Investments □
My Family will Pay
The national average annual cost of care in
[insert year] was [insert $ amount], but this figure varies across the county.
In ten years the national average annual cost would be about [insert $ amount]
if costs increase 5% annually.
What elimination period are you considering?
Number of days _______ Approximate cost $__________ for that period of care.
How are you planning to pay for your care during the
elimination period? (check one)
□
From my Income □
From my Savings/Investments □
My Family will Pay
Questions
Related to Your Savings and Investments
Not
counting your home, about how much are all of your assets (your savings and
investments) worth? (check one)
□
Under $20,000 □
$20,000-$30,000 □
$30,000-$50,000 □
Over $50,000
How
do you expect your assets to change over the next ten years? (check one)
□
Stay about the same □
Increase □
Decrease
If you are buying this policy to protect your assets
and your assets are less than $30,000, you may wish to consider other options
for financing your long-term care.
Disclosure
Statement
|
□
|
The
answers to the questions above describe my financial situation.
|
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|
or
|
|
□
|
I
choose not to complete this information.
|
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|
(Check
one)
|
|
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|
|
□
|
I
acknowledge that the carrier and/or its agent (below) has reviewed this
|
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form
with me including the premium, premium rate increase history and
|
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potential
for premium increases in the future. [For direct mail situations,
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use
the following: I acknowledge that I have reviewed this form including the
premium, premium rate increase history and potential for premium increases in
the future.] I understand the above disclosures. I understand that the rates for this policy may increase in the future.
(This box must be checked.
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Signed:
____________________________________ _____________________________
(Applicant) (Date)
[□
I explained to the applicant the importance of completing this information.
Signed:
____________________________________ _____________________________
(Agent)
(Date)
Agent's
Printed
Name:
________________________________________________________________________]
[In
order for us to process your application, please return this signed statement
to [name of company], along with your application.]
[My
agent has advised me that this policy does not seem to be suitable for me.
However, I still want the company to consider my application.
Signed:
____________________________________
____________________________]
(Applicant) (Date)