West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-32 - Long-Term Care Insurance › Appendix B

Current through Register Vol. XLI, No. 28, July 12, 2024
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 a
nd 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 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.