Illinois Administrative Code › Title 50 - INSURANCE › Part 2012 - LONG-TERM CARE INSURANCE › Exhibit F - Long-Term Care Insurance Personal Worksheet

Current through Register Vol. 48, No. 28, July 12, 2024
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.
The company will ask you to fill out this worksheet to help you
				and the company decide if you should buy this policy. By State law, the
				insurance company must fill out part of the information on this
				worksheet.
Premium Information
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'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.]
[The issuer shall list each premium increase it has instituted
				on this or similar policy forms in this State or any other state during the
				last 10 years. The list shall provide the policy form, the calendar years the
				form was available for sale, and the calendar year and the amount (percentage)
				of each increase.]
[The insurer shall provide minimum and maximum percentages if
				the rate increase is variable by rating characteristics. The insurer may
				provide, in a fair manner, additional explanatory information as
				appropriate.]
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 were raised substantially?]
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 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
						  day _____ 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
Click here to view
				image
The company may contact you to verify your answers.
[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.]