North Dakota Administrative Code › Title 45 - Insurance, Commissioner of › Article 45-06 - Accident and Health Insurance › Chapter 45-06-05.1 - LONG-TERM CARE INSURANCE MODEL REGULATION › Appendix B - Personal Worksheet

Current through Supplement No. 393, July, 2024
Long-Term Care Insurance Personal Worksheet
This worksheet will help you understand some important
				  information about this type of insurance. State law requires companies issuing
				  this [policy] [certificate] [rider] to
give
you some important
				  facts about premiums and premium increases and to
ask
you some
				  important questions to help you and the company decide if you should buy this
				  [policy] [certificate] [rider]. Long-term care insurance can be expensive and
				  it may not be right for everyone.
Premium Information
The premium for the coverage you are considering will
				  be
[$ ______ per [insert payment interval]
or a total of
[$ _____ per year] [a one-time
				  single premium of $ ______ .]
The premium quoted in this worksheet is not guaranteed
				  and may change during the underwriting process and in the future while this
				  [policy] [certificate] [rider] is in force.
Type of Policy and The Company's Right to Increase
				  Premiums on the Coverage You Choose:
[Noncancellable - The company
cannot
increase
				  your premiums on this [policy] [certificate] [rider].]
[Guaranteed renewable - The company
can
increase
				  your premiums on this [policy] [certificate] [rider] in the future if it
				  increases the premiums for all [policies] [certificates] [riders] like yours in
				  this state.]
[Paid-up - This [policy] [certificate] [rider] will be
				  paid-up after you have paid all of the premiums specified in your [policy]
				  [certificate] [rider].]
Premium Increase History
[Name of company] has sold long-term care insurance since
				  [year] and has sold this [policy] [certificate] [rider] since [year].
[The company has never increased its premiums for any
				  long-term care [policy] [certificate] [rider] it has sold in this state or any
				  other state.]
[The company has not increased its premiums for this [policy]
				  [certificate] [rider] or similar [policies] [certificates] [riders] in this
				  state or any other state in the last 10 years.]
Questions About Your Income
You do
not
have to answer the questions that
				  follow. They are intended to make sure you have thought about how you'll pay
				  premiums and the cost of care your insurance does not cover. If you do not want
				  to answer these questions, you should understand that the company might refuse
				  to insure you.
What resources will you use to pay your premium?
Current income from employment Current income from
				  investments Other current income Savings Sell investments Sell other assets
				  Money from my family Other
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] [certificate] [rider] if the premiums will be more than 7% of your
				  income.
Could you afford to keep this [policy] [certificate]
				  [rider] if your spouse or partner dies first?
Yes No Had not thought about itDo not know Does not
				  apply
What would you do if the premiums went up, for example,
				  by 50%?
Pay the higher premium Call the company/agentReduce
				  benefits
Drop the [policy] [certificate] [rider]Do not know
What is your household annual income from all sources?
				  (check one)
[Less than $10,000][$10,000-$19,999] [$20,000-$29,999]
				  [$30,000-$50,000] [More than $50,000]
Do you expect your income to change over the next 10
				  years? (check one)
No Yes, expect increaseYes, expect decrease
Yes No Do not know
Will you buy inflation protection? (check one)
Yes No
Inflation may increase the cost of long-term care in the
				  future.
If you do not buy inflation protection, how will you
				  pay for the difference between future costs and your daily benefit
				  amount?
From my incomeFrom savingsFrom investments Sell other assets
				  Money from my family Other
The national average annual cost of long-term care in [insert
				  year] was [insert $ amount], but this figure varies across the country. In 10
				  years the national average annual cost would be about [insert $ amount] if
				  costs increase 5% annually.
What [elimination period] [waiting period] [cash
				  deductible] are you considering?
[Number of days _______ in [elimination period] [waiting
				  period]
Approximate cost of care for that period: $ ________
($xxx per day times number of days in [elimination period]
				  [waiting period], where "xxx" represents the most recent estimate of the
				  national daily average cost of long-term care)]
[Cash Deductible $ _______ ]
How are you planning to pay for your care during the
				  [elimination period] [waiting period] [deductible period]? (check all that
				  apply)
From my incomeFrom my savings/investments My family will
				  pay
Questions About Your Savings and Investments
Not counting your home, about how much are all of your
				  assets (your savings and investments) worth? (check one)
[Less than $20,000] [$20,000-$29,999] [$30,000-$50,000] [More
				  than $50,000]
Do you expect your assets to change over the next 10
				  years? (check one)
No Yes, expect to increaseYes, expect to decrease
If you are buying this [policy] [certificate] [rider] to
				  protect your assets and your assets are less than $50,000, experts suggest you
				  think about other ways to pay for 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 agree that the company and/or its agent (below) has
							 reviewed this worksheet with me, including the premium, premium increase
							 history, and potential for premium increases in the future. I understand the
							 information contained in this worksheet. (This box must be
							 checked.)
Signed: __________________________
				  ____________________________
(Applicant) (Date)
[I explained to the applicant the importance of completing
				  this information.
Signed: __________________________
				  ____________________________
(Agent)(Date)
Agent's Printed Name: ]
[In order for us to process your application, please return
				  this signed worksheet to [name of company], along with your
				  application.]
[My agent has advised me that this long-term care insurance
				  [policy] [certificate] [rider] does not seem to be suitable for me. However, I
				  still want the company to consider my application.]
Signed: __________________________
				  ____________________________
(Applicant) (Date)
Someone from the company may contact you to discuss your
				  answers and the suitability of this [policy] [certificate] [rider] for
				  you.