Indiana Administrative Code › Title 760 - DEPARTMENT OF INSURANCE › Article 2 - LONG TERM CARE INSURANCE COVERAGE › Rule 19.5 - Standard Forms › Section 19.5-1 - Long term care insurance personal worksheet

Current through July 10, 2024
Authority: IC
				  27-8-12-7
Affected: IC
				  27-8-12
Sec. 1.
The long term care insurance personal worksheet is as
				  follows:
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 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 (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 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, 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.
Or
I choose not to complete this information.
(Check one.)
I acknowledge that the carrier and/or its insurance producer
				  (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
				  must be checked).
Signed: _________________________________________
(Applicant)
_________________________________________
(Date)
[I explained to the applicant the importance of completing
				  this information.
Signed: _________________________________________
(Insurance Producer)
_________________________________________
(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)
The company may contact you to verify your answers.