South Carolina Code of Regulations › Chapter 69 - DEPARTMENT OF INSURANCE › Subchapter 69-44 - LONG TERM CARE INSURANCE › Appendix B - Long-term Care Insurance

Current through Register Vol. 48, No. 6, June 28, 2024
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.]
[Note: A company may use the first bracketed sentence above
				only if it has never increased rates under any prior policy forms in this state
				or any other state. The issuer shall list each premium increase it has
				instituted on this or similar policy forms in this state or any other state
				during the last 10 years. The list shall provide the policy form, the calendar
				years the form was available for sale, and the calendar year and the amount
				(percentage) of each increase. The insurer shall provide minimum and maximum
				percentages if the rate increase is variable by rating characteristics. The
				insurer may provide, in a fair manner, additional explanatory information as
				appropriate.]
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%?]
[Note: The issuer is not required to use the bracketed sentence
				if the policy is fully paid up or is a noncancellable policy.]
What is your annual income? (check one) [ ] Under $10,000 [ ]
				$[10-20,000] [ ] $[20-30,000] [ ] $[30-50,000] [ ] Over $50,000
[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 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.
[Note: The projected cost can be based on federal estimates in
				a current year. In the above statement, the second figure equals 163% of the
				first figure.]
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 agent (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:
				________________________________________________________________
(Agent) (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.