Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 3 - Casualty Insurance › Appendix 2

Current through June 24, 2024
LONG-TERM CARE INSURANCE
Personal Worksheet
People buy long-term care insurance for a variety of reasons.
				These reasons include avoiding spending assets for long-term care, to make sure
				there are choices regarding the type of care received, to protect family
				members from having to pay for care, or to decrease the chances of going on
				Medicaid. However, long-term care insurance can be expensive and is not
				appropriate for everyone. State law requires the insurance company to ask you
				to complete this worksheet to help you and the insurance company determine
				whether you should buy this policy.
PREMIUM
Policy Form Number(s) _____________________
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 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.]
Note:
The insurer shall use the bracketed sentence
				or sentence applicable to the product offered. If a company includes a
				statement regarding not having raised rates, it shall disclose the company's
				rate increases under prior policies providing essentially similar
				coverage.
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 increase(s).]
QUESTIONS RELATED TO YOUR INCOME
[] Income [] Savings [] Family members
[Have you considered whether you could afford to keep this
				policy if the premiums were raised, for example, by 20%?]
Note:
The insurer shall use the bracketed sentence
				unless the policy is fully paid up or is a noncancellable policy.
What is your annual income? (check one)
[] Under $10,000 [] $10,000-20,000 [] $20,000-30,000 []
				$30,000-50,000 []Over $50,000
Note:
The insurer 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.
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, what is the approximate value of all of
				your assets (savings and investments)? (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.
[] I acknowledge that the carrier 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 shall be checked).
Signed:_____________________________ ______________
(Applicant)
(Date)
(I) explained to the applicant the importance of completing
				this information.)
Signed:____________________________ _______________
(Agent)
(Date)
Agent's Printed Name:_______________________________
Note:
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 appear to be
				suitable for me. However, I still want the company to consider my
				application.]
Signed:_____________________________ _______________
(Applicant)
(Date)