Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 89a - LONG-TERM CARE INSURANCE MODEL REGULATION › Appendix B - LONG-TERM CARE INSURANCE PERSONAL WORKSHEET

Current through Register Vol. 54, No. 28, July 13, 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 Pennsylvania 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 may 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 a long-term care policy it has sold in this State or another state.] [The
				  company has not raised its rates for this policy form or similar policy forms
				  in this State or another 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
[ ] 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 [ ].
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 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 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: _________________________
____________ ____________
(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 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.
This appendix cited in 31 Pa. Code §
											89a.108 (relating to required
					 disclosure of rating practices to consumers); and 31 Pa. Code §
											89a.121 (relating to
					 suitability).