Del. Admin. Code tit. 18, 1400, 1404, app B
Long Term Care Insurance
Personal Worksheet
People buy long-term care insurance for a variety of reasons. Some don't want to use thier 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 to 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 (non cancellable/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 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 who 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
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
Question Related to Your Savings and Investments
Not counting your home, about how much are all of your assets (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 information provided above accurately describes my financial situation. | ®I choose not to complete this information. |
Signed:
(Applicant)
(Date)
[® I explained to the applicant the importance of completing this information.
Signed:
(Producer)
(Date)
Producer's Printed Name: ]
[Note: In order for us to process your application, please return this signed statement to [name of company], along with your application.]
[My producer has advised me that this policy does not appear to be suitable for me. However, I still want the company to consider my application.
Signed: ]
(Applicant)
(Date)
Drafting Note: Choose the appropriate sentences depending on whether this is a direct mail or agent sale.
The company may contact you to verify your answers.
Drafting Note: When the Long-Term Care Insurance Personal Worksheet is furnished to employees and their spouses under employer group policies, the text from the heading "Disclosure Statement" to the end of the page may be removed.
Del. Admin. Code tit. 18, 1400, 1404, app B