Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-83 - Long-term care insurance rules › Section 284-83-170 - Form of personal worksheet

Current through Register Vol. 24-14, July 15, 2024
The following form of personal worksheet must be used by
				issuers in the sale of long-term care insurance policies.
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 or 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.]
				[Issuers must use appropriate bracketed statement. Rate guarantees must 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 ten years.] [The company has
				raised its premium rates on this policy form or similar policy forms in the
				last ten 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%?]
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 issuer and/or its [agent] [insurance
				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:
[(Agent)] [(Insurance Producer)] (Date)
[Agent's] [Insurance 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 [agent] [insurance 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)
Drafting Note:
Choose the appropriate sentences
				depending on whether this is a direct mail or [agent] [insurance producer]
				sale.
The company may contact you to verify your answers.
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.
Statutory Authority:
				  RCW
				  48.02.060,
				  48.83.070,
				  48.83.110,
				  48.83.120,
				  48.83.130(1), and
				  48.83.140(4)(a).
				  08-24-019 (Matter No. R 2008-09), §
										284-83-170, filed 11/24/08,
				  effective 12/25/08.
Reviser's note:
The brackets and enclosed
				  material in the text of the above section occurred in the copy filed by the
				  agency.