Nebraska Administrative Code › Topic - INSURANCE, DEPARTMENT OF › Title 210 - NEBRASKA DEPARTMENT OF INSURANCE › Chapter 46 - LONG-TERM CARE INSURANCE › Appendix B - LONG TERM CARE INSURANCE PERSONAL WORKSHEET

Current through June 17, 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.
By state law, the insurance company must ask you to fill out
				  this worksheet to help you and the company decide if you should buy this
				  policy.
Premium
The premium for the coverage you are thinking about buying
				  will be [$ per month, or $ per year,] [a one-time single premium of $ .]
[The company cannot raise your rates on this policy.] [The
				  company has a right to increase premiums in the future.] The company has sold
				  long-term care insurance since [year] and has sold this policy since [year].
				  [The last rate increase for this policy in this state was in [year], when
				  premiums went up an average of %]. [The company has not raised its rates for
				  this policy.]
Drafting Note
: The issuer shall use the
				  bracketed sentence or sentences applicable to the product offered. If a company
				  includes a statement regarding not having raised rates, it must disclose the
				  company's rate increases under prior policies providing essentially similar
				  coverage. The issuer may include rate information for up to two policy forms if
				  the issuer has not changed rates on either policy form or for prior policies
				  providing essentially similar coverage.
* [Have you considered whether you could afford to keep this
				  policy if the premiums went up, for example, by 20%?]
Drafting Note
: The issuer shall use the
				  bracketed sentence unless the policy is fully paid up or is a noncancellable
				  policy.
How will you pay each year's premium?
* From my Income From my Savings \ Investments My Family will
				  pay
Income
What is your annual income? (check one)
Under $10,000 $[ 10-20,000] $[ 20-30,000] [$ 30-50,000] Over
				  $50,000
Drafting Note
: 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 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.
Savings and Investments
Not counting your home, about how much are all of your assets
				  worth (your savings and investments)? (check one)
Under $20,000 $20,00-$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 answer to the questions above describe 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:__________________________________
				  _____________________________
(Applicant)
(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 seem 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.