Wyoming Administrative Code › Agency 044 - Insurance Dept › Sub-Agency 0002 - General Agency, Board or Commission Rules › Chapter 37 - LONG-TERM CARE REGULATION › Appendix B - Long Term Care Insurance Personal Worksheet

Current through July 13, 2024
People buy long-term care insurance for many reasons. Some do
				  not 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 do not want
				  their family to have to pay for care or do not 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.]
Drafting 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?
G
From my Income
G
From my
				  Savings/Investments
G
My Family will Pay
[
G
Have you considered whether you could afford
				  to keep this policy if the premiums went up, for example, by 20%?]
Drafting Note:
The issuer is not required to use
				  the bracketed sentence if the policy is fully paid up or is noncancellable
				  policy.
What is your annual income? (check one) G Under $10,000 G
				  $[10-20,000] G $[20-30,000] G $[30-50,000] G Over $50,000
Drafting 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)
G
No change
G
Increase
G
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)
G
Yes
G
No
If not, have you considered how you will pay for the
				  difference between future costs and your daily benefit amount?
G
From my Income
G
From my Savings/Investments
G
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.
Drafting 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)
G
From my Income
G
From my
				  Savings/Investments
G
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)
G
Under $20,000
G
$20,000-$30,000
G
$30,000-$50,000 G Over $50,000
How do you expect your assets to change over the next ten
				  years? (check one)
G
Stay about the same
G
Increase
G
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
G
The answers to the questions above describe my
				  financial situation.
Or
G
I choose not to complete this
				  information.
(Check one.)
G
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)
[
G
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)
Drafting Note:
Choose the appropriate sentences
				  depending on whether this is a direct mail or agent sale.
The company may contact you to verify your
				  answers.
Drafting 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.