Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 425 - LONG-TERM CARE INSURANCE › Appendix 031-425-B

Current through 2024-29, July 17, 2024
Applicant Suitability 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 to fill out the rest to
				  help you and the company decide if you should buy this policy.
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
(noncancelable/guaranteed
				  renewable): __________________________
The Company's Right to Increase Premiums:
[Insurer shall use appropriate bracketed statement, but shall
				  not show rate guarantees on this form]:
[The company can never raise your rates on this policy.] [The
				  company has a right to increase premiums on this policy form in the future,
				  provided that it raises rates for all policies in the same class in this
				  state.]
Rate Increase History
[A company may use the first bracketed sentence only if it
				  has never increased rates under any prior policy form in this state or any
				  other state.]
The company has sold long-term care insurance since [year]
				  and has sold this policy form since [year].
[The company has never raised its rates for any long-term
				  care policy it has sold in this state or in any other state.] [The company has
				  not raised its premium rates for this policy form or similar policy forms in
				  this state or in 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. The following summary includes all such rate increases in the last 10
				  years: [ ]. [Instructions to issuer: The issuer shall list each premium
				  increase it has instituted on this policy form or any similar policy form
				  issued in this state or any other state during the 10 years immediately
				  preceding the date of first solicitation of the applicant. The summary shall
				  list the policy form identification number, each calendar year the form was
				  available for sale in any state, and the calendar year and the amount
				  (percentage) of each increase. The issuer shall provide minimum and maximum
				  percentages if the rate increase is variable by rating characteristics. The
				  issuer may provide, in a clear and fair manner, additional explanatory
				  information which will assist the applicant in understanding the rate increase
				  history concerning the described form(s).]
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, for example, by 20%?]
[
The issuer shall use the bracketed sentence
				  unless the policy is fully paid up or is a noncancelable policy.]
What is your annual income? (check one)
[] Under $10,000 [] $[10-20,000] [] $[20-30,000] []
				  $[30-50,000] [] Over $50,000
[The issuer 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 10
				  years the national average annual cost will be approximately [insert $ amount]
				  if costs increase 5% each year.
What elimination period are you considering?
Number of days:
Approximate $ cost is 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, approximately how much are all 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.
Or
[] I choose not to complete this information.
(check one)
[] I acknowledge that the insurer or its producer
							 named below, or both of them, reviewed this form with me, including each of the
							 following subjects: the premium amount; the company's premium rate increase
							 history; and the potential for premium increases in the future. [For direct
							 mail solicitations, use the following: I acknowledge that I have reviewed this
							 form, including the information regarding the premium; the company's premium
							 rate increase history; and the potential for premium increases in the future.]
							 I understand these disclosures,
specifically including that the premiums
							 for this policy may increase in the future.
(This box must be checked,
							 and the company will not be able to act on your application until it is
							 checked.)
Signed:____________________________________
(Applicant) (Date)
[ [] I explained to the applicant the importance of
				  completing this information.
Signed:____________________________________
(Producer) (Date)
Producer'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 producer or other representative 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)
The company may contact you to verify your
				  answers.