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Chapter 20:06:21




SEE: § 20:06:21:53.02





















          Source: 28 SDR 157, effective May 19, 2002.

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 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 county. 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, 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.




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)



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