Wis. Admin. Code Office of the Commissioner of Insurance, ch. Ins 3, app 2
LONG-TERM CARE INSURANCE
Personal Worksheet
People buy long-term care insurance for a variety of reasons. These reasons include avoiding spending assets for long-term care, to make sure there are choices regarding the type of care received, to protect family members from having to pay for care, or to decrease the chances of going on Medicaid. However, long-term care insurance can be expensive and is not appropriate for everyone. State law requires the insurance company to ask you to complete this worksheet to help you and the insurance company determine whether you should buy this policy.
PREMIUM
Policy Form Number(s) _____________________
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 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 may not be shown on this form.]
Note: The insurer shall use the bracketed sentence or sentence applicable to the product offered. If a company includes a statement regarding not having raised rates, it shall disclose the company's rate increases under prior policies providing essentially similar coverage.
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 increase(s).]
QUESTIONS RELATED TO YOUR INCOME
[] Income [] Savings [] Family members
[Have you considered whether you could afford to keep this policy if the premiums were raised, for example, by 20%?]
Note: The insurer shall use the bracketed sentence unless the policy is fully paid up or is a noncancellable policy.
What is your annual income? (check one)
[] Under $10,000 [] $10,000-20,000 [] $20,000-30,000 [] $30,000-50,000 []Over $50,000
Note: The insurer may choose the numbers to put in the brackets to fit its suitability standards.
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 country. 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, what is the approximate value of all of your assets (savings and investments)? (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. or
[] I choose not to complete this information.
[] I acknowledge that the carrier or its agent (below) has reviewed this form with me including the premium, premium rate increase history and potential for premium increases in the future. [For direct mail situations, 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 shall be checked).
Signed:_____________________________ ______________
(Applicant)
(Date)
(I) explained to the applicant the importance of completing this information.)
Signed:____________________________ _______________
(Agent)
(Date)
Agent'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 agent 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)
Wis. Admin. Code Office of the Commissioner of Insurance, ch. Ins 3, app 2