<html> <head> <title>Rule 20:06:21:0E Personal Worksheet.</title> <META NAME="Keywords" Content="Administrative Rules 20:06:21:0E"> <META NAME="Description" Content="Administrative Rules 20:06:21:0E Personal Worksheet."> <meta http-equiv=Content-Type content="text/html; charset=windows-1252"> <meta name=Generator content="Microsoft Word 15 (filtered)"> <style> <!-- /* Font Definitions */ @font-face {font-family:"Cambria Math"; panose-1:2 4 5 3 5 4 6 3 2 4;} @font-face {font-family:Tahoma; panose-1:2 11 6 4 3 5 4 4 2 4;} @font-face {font-family:Times; panose-1:2 2 6 3 5 4 5 2 3 4;} /* Style Definitions */ p.MsoNormal, li.MsoNormal, div.MsoNormal {margin:0in; margin-bottom:.0001pt; font-size:10.0pt; font-family:"Times",serif; color:black;} h3 {mso-style-link:"Heading 3 Char"; margin:0in; margin-bottom:.0001pt; text-align:justify; page-break-after:avoid; font-size:12.0pt; font-family:"Times New Roman",serif; color:black; font-weight:normal;} h5 {mso-style-link:"Heading 5 Char"; 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font-family:"Times New Roman",serif; font-weight:bold;} span.BalloonTextChar {mso-style-name:"Balloon Text Char"; mso-style-link:"Balloon Text"; font-family:"Tahoma",sans-serif;} .MsoChpDefault {font-size:10.0pt; color:black;} @page WordSection1 {size:8.5in 11.0in; margin:49.7pt 1.0in 49.7pt 63.35pt;} div.WordSection1 {page:WordSection1;} --> </style> </head> <body lang=EN-US link=blue vlink="#954F72"> <div class=WordSection1> <p class=MsoNormal><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal align=center style='text-align:center'><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>DEPARTMENT OF LABOR AND REGULATION</span></p> <p class=MsoNormal align=center style='text-align:center'><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal align=center style='text-align:center'><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>DIVISION OF INSURANCE</span></p> <p class=MsoNormal align=center style='text-align:center'><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal align=center style='text-align:center'><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal align=center style='text-align:center'><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal align=center style='text-align:center'><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal align=center style='text-align:center'><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>PERSONAL WORKSHEET</span></p> <p class=MsoNormal align=center style='text-align:center'><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal align=center style='text-align:center'><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal align=center style='text-align:center'><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>Chapter 20:06:21</span></p> <p class=MsoNormal align=center style='text-align:center'><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal align=center style='text-align:center'><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>APPENDIX E</span></p> <p class=MsoNormal align=center style='text-align:center'><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal align=center style='text-align:center'><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>SEE: &#167;</span><span style='font-size:12.0pt'> </span><span style='font-size:12.0pt;font-family: "Times New Roman",serif'>20:06:21:53.02</span></p> <p class=MsoNormal align=center style='text-align:center'><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal align=center style='text-align:center'><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal align=center style='text-align:center'><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal align=center style='text-align:center'><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal align=center style='text-align:center'><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal align=center style='text-align:center'><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal align=center style='text-align:center'><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal align=center style='text-align:center'><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal align=center style='text-align:center'><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal align=center style='text-align:center'><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal align=center style='text-align:center'><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal align=center style='text-align:center'><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal align=center style='text-align:center'><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal align=center style='text-align:center'><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal align=center style='text-align:center'><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal align=center style='text-align:center'><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal align=center style='text-align:center'><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal align=center style='text-align:center'><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal align=center style='text-align:center'><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal align=center style='text-align:center'><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>Source:</b> 28 SDR 157, effective May 19, 2002; 44 SDR 184, effective June 25, 2018.</span></p> <b><span style='font-size:12.0pt;font-family:"Times New Roman",serif'><br clear=all style='page-break-before:always'> </span></b> <h6 align=center style='text-align:center'>Long-Term Care Insurance</h6> <h5>Personal Worksheet</h5> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal style='text-align:justify'><b><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>Drafting Note:</span></b><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> Companies shall at a minimum provide all of the information shown below and</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> </span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>in the same order. The company may include additional information related to this long-term</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> </span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>care insurance coverage in relevant and readable language. Bracketed statements indicate the</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> </span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>companies should choose the applicable statement, are allowed flexibility in inserting numerical</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> </span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>ranges, etc.</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal style='text-align:justify'><b><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>Long-Term Care Insurance Personal Worksheet</span></b></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>This worksheet will help you understand some important information about this type of insurance.</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> </span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>State law requires companies issuing this [policy] [certificate] [rider] to <b>give</b> you some important</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> </span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>facts about premiums and premium increases and to <b>ask</b> you some important questions to help </span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>y</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>ou</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> </span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>and the company decide if you should bu</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>y</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> this [policy] [certificate] [rider]. Long-te</span><span style='font-size:12.0pt;font-family: "Times New Roman",serif'>rm</span><span style='font-size:12.0pt;font-family: "Times New Roman",serif'> care</span><span style='font-size:12.0pt;font-family: "Times New Roman",serif'> </span><span style='font-size:12.0pt;font-family: "Times New Roman",serif'>insurance can be expensive and it may not be right for everyone.</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal style='text-align:justify'><b><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>Premium Information</span></b></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal style='text-align:justify'><b><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>The premium for the coverage you are considering will be</span></b><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> [$</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>____</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> per [insert payment interval</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>] </span><b><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>or a total of</span></b><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> </span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>[$</span><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>______</span><span style='font-size:12.0pt; font-family:"Times New Roman",serif'> per</span><span style='font-size:12.0pt; font-family:"Times New Roman",serif'> y</span><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>ear] [a one-time single premium of</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> </span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>$</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>_______</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>].</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal style='text-align:justify'><b><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>The premium quoted in this worksheet is not guaranteed and may change during the</span></b><b><span style='font-size: 12.0pt;font-family:"Times New Roman",serif'> </span></b><b><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>underwriting process and in the future while this [policy] [certificate] [rider</span></b><b><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>]</span></b><b><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> is in force.</span></b></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal style='text-align:justify'><b><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>Drafting Note:</span></b><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> Companies will insert payment interval - monthly, quarterl</span><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>y</span><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>, etc. and the</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> </span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>appropriate dollar amount.</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal style='text-align:justify'><b><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>Type of Policy &amp; The Company's Right to Increase Premiums on the Coverage You Choose:</span></b></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>[Noncancellable - The company <b>cannot</b> increase your premiums on this [policy] </span><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>[</span><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>certificate] [rider]].</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>[Guaranteed renewable - The company <b>can</b> increase your premiums on this [policy]</span><span style='font-size:12.0pt; font-family:"Times New Roman",serif'> </span><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>[certificate] [rider] in the future if it increases the premiums for all [policies] [certificates] [riders]</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> </span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>like yours in this state.]</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>[Paid-up - This [policy] </span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>[</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>certificate] [rider] will be paid-up after </span><span style='font-size:12.0pt;font-family: "Times New Roman",serif'>y</span><span style='font-size:12.0pt;font-family: "Times New Roman",serif'>ou have paid all of the premiums</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> </span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>specified in your [policy</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>]</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> [certificate] [rider]].</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal style='text-align:justify'><b><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>Drafting Note:</span></b><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> Companies will insert the appropriate policy type and the associated bracketed</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> </span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>statement. Premium guarantees shall not be shown on this form.</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal style='text-align:justify'><b><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>P</span></b><b><span style='font-size: 12.0pt;font-family:"Times New Roman",serif'>remium Increase History</span></b></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>[Name of</span><span style='font-size: 12.0pt;font-family:"Times New Roman",serif'> </span><span style='font-size: 12.0pt;font-family:"Times New Roman",serif'>company</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>] </span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>has sold </span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>l</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>ong-tenn care insurance since [yea</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>r]</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> and has sold this [policy]</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> </span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>[certificate] [rider] since [year].</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>[The company has never increased its premiums for any long-te</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>rm</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> care [policy] [certificate] [rider]</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> </span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>it has sold in this state or any other state.]</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>[The company has not increased its premiums for this [policy] [certificate] [rider] or similar</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> </span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>[policies] [certificates] [riders] in this state or any other state in the last 10 years.]</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>[The company has increased its premiums on this [policy] [certificate] [rider] or similar [policies]</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> </span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>[certificates] [riders] in the last 10 years. A summary of those premium increases follows.</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>Drafting Note: If the summary of premium increases is extensive, the company may disclose the</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> </span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>required premium increase history via an addendum attached to this worksheet. The company</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> </span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>may substitute the language below for the last sentence in the paragraph above and include the</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> </span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>full summary as an attachment to this worksheet.</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&quot;Over the past 3 </span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>y</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>ears</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>,</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> the company has increased premiums by</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> ___</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>%.&quot;</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> </span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>A summary of </span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>p</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>remium</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> </span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>increases in the last 10 </span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>y</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>ears is attached to this worksheet&quot;.</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>Companies that have increased premiums b</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>y</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> 30% or more in the last ten </span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>y</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>ears must include the</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> </span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>following statement: &quot;There was a 30% or greater premium</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> </span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>increase in [insert year].&quot; &quot;A summary of premium increases in the last 10 years is attached to</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> </span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>this worksheet.&quot;</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal style='text-align:justify'><b><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>Questions About Your Income</span></b></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>You do <b>not</b> have to answer the questions that follow. They are intended to make sure you have thought</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> </span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>about how you'll pay premiums and the cost of care your insurance does not cover. If you do not want</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> </span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>to answer these questions</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>,</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> you should understand that the company might refuse to insure you.</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal style='text-align:justify'><b><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>What resources will you use to pay your premium?</span></b></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&#1054; Current income from employment O Current income from investments</span><span style='font-size:12.0pt;font-family: "Times New Roman",serif'> </span><span style='font-size:12.0pt;font-family: "Times New Roman",serif'>O Other current</span><span style='font-size:12.0pt; font-family:"Times New Roman",serif'> </span><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>income</span><span style='font-size:12.0pt; font-family:"Times New Roman",serif'> </span><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>O Savings O Sell investments O Sell other assets</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> </span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>O Money from my family O Other</span><span style='font-size:12.0pt;font-family: "Times New Roman",serif'>____</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal style='text-align:justify'><i><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>l</span></i><i><span style='font-size: 12.0pt;font-family:"Times New Roman",serif'>f y</span></i><i><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>ou </span></i><i><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>w</span></i><i><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>ill be paying premiums with mone</span></i><i><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>y</span></i><i><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> received only f</span></i><i><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>r</span></i><i><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>om your own income, a rule o</span></i><i><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>f </span></i><i><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>thumb is that </span></i><i><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>you </span></i><i><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>may not be able to </span></i><i><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>af</span></i><i><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>ford this [policy</span></i><i><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>]</span></i><i><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> [certificate</span></i><i><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>]</span></i><i><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> [</span></i><i><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>ri</span></i><i><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>der</span></i><i><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>]</span></i><i><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> if</span></i><i><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> </span></i><i><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>the premiums will be more than 7% o</span></i><i><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>f y</span></i><i><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>our</span></i><i><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> </span></i><i><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>income.</span></i></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal style='text-align:justify'><b><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>Could you afford to keep this [policy] [certificate] [rider] if your spouse or partner dies first?</span></b></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>O Yes</span><span style='font-size:12.0pt; font-family:"Times New Roman",serif'> </span><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;O No</span><span style='font-size:12.0pt; font-family:"Times New Roman",serif'> </span><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;O Had not thought about it</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> </span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>&nbsp;O Do not know </span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>&nbsp;</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>O Does not apply</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal style='text-align:justify'><b><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>[</span></b><b><span style='font-size: 12.0pt;font-family:"Times New Roman",serif'>What would you do if the premiums went up, for example, by 50%</span></b><b><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>?</span></b></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>O Pay the higher premium </span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>&nbsp;</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>O Call the company/agent</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> </span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>&nbsp;O Reduce benefits</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> </span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>&nbsp;O Drop the <b>[policy</b></span><b><span style='font-size:12.0pt;font-family: "Times New Roman",serif'>] </span></b><b><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>[certificate</span></b><b><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>]</span></b><b><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> </span></b><b><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>[</span></b><b><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>rider</span></b><b><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>]</span></b><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> </span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>&nbsp;O Do not know]</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal style='text-align:justify'><b><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>Drafting Note:</span></b><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> The company is not required to use the bracketed question above if the coverage</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> </span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>is fully paid up or is noncancellable.</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal style='text-align:justify'><b><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>What is your household annual income from all sources?</span></b><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> (check one)</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>O [Less than $10,000] O $[10,000-19,999] O $[20</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>,</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>000-29,999] O $</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>[</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>30,000-50</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>,</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>000] O [More</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>than $50</span><span style='font-size: 12.0pt;font-family:"Times New Roman",serif'>,</span><span style='font-size: 12.0pt;font-family:"Times New Roman",serif'>000]</span></p> <p class=MsoNormal style='text-align:justify'><b><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>Drafting Note:</span></b><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> The companies may choose the income ranges to put in the brackets to fit its</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> </span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>suitability standards.</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal style='text-align:justify'><b><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>Do </span></b><b><span style='font-size: 12.0pt;font-family:"Times New Roman",serif'>y</span></b><b><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>ou expect your income to change over the next 10 </span></b><b><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>y</span></b><b><span style='font-size: 12.0pt;font-family:"Times New Roman",serif'>ears?</span></b></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>(check one)</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>O No O Yes, expect increase O Yes, expect decrease</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal style='text-align:justify'><b><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>If you plan to pay premiums from your income, have you thought about how a change in</span></b><b><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> </span></b><b><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>your income would affect your ability to continue to pay the premium?</span></b></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>O Yes O No O Do not know</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal style='text-align:justify'><b><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>Will you buy inflation protection?</span></b></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>(check one) O Yes O No</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal style='text-align:justify'><i><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>Inflation may increase the cost o</span></i><i><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>f </span></i><i><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>long-term care in the f</span></i><i><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>u</span></i><i><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>ture.</span></i></p> <p class=MsoNormal style='text-align:justify'><b><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>If you do not buy inflation protection, how will you pay for the difference between future costs</span></b><b><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> </span></b><b><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>and your daily benefit amount?</span></b></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>O From my income O From savings O From investments O Sell other assets O Money from my famil</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>y</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> O</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> </span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>Other</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal style='text-align:justify'><i><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>The national average annual cost of</span></i><i><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> l</span></i><i><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>ong-term care in [insert vear</span></i><i><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>]</span></i><i><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>·was [insert</span></i><i><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> </span></i><i><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>$ amount</span></i><i><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>]</span></i><i><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>, but this figure</span></i><i><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> </span></i><i><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>varies across the countr</span></i><i><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>y</span></i><i><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>. In ten </span></i><i><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>y</span></i><i><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>ears the national average annual cost would be about [insert</span></i><i><span style='font-size: 12.0pt;font-family:"Times New Roman",serif'> </span></i><i><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>$ amount</span></i><i><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>]</span></i><i><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> i</span></i><i><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>f </span></i><i><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>costs increase 5% annually.</span></i></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>Drafting Note: The projected cost can be based on federal estimates in a current year. This figure</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> </span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>should also be used when calculating the cost of long-term care in the &quot;approximate cost $</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>____ </span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>for that period of care&quot; question found below. In the above statement, the second figure will</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> </span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>equal 163% of the first figure.</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>What [elimination period] </span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>[</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>waiting period] [cash deductible] are you considering?</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>[Number of days</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> _____</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> in [elimination period][ waiting period]</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>Approximate cost of care for this period:</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> </span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>$</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>______</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>($xxx per day times number of days in [elimination period] [waiting period]</span><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>,</span><span style='font-size:12.0pt; font-family:"Times New Roman",serif'> where &quot;xxx&quot;</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> </span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>represents the most recent estimate of the national daily average cost of long-te</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>rm</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> care)]</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>[Cash Deductible</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> </span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>$</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>_______</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>.</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal style='text-align:justify'><b><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>How do you plan to pay for your care during the [elimination period] [waiting period]</span></b><b><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> </span></b><b><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>[deductible period]?</span></b><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> (check all that apply)</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>O From m</span><span style='font-size: 12.0pt;font-family:"Times New Roman",serif'>y</span><span style='font-size: 12.0pt;font-family:"Times New Roman",serif'> income O From my savings/investments O My family will pay</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal style='text-align:justify'><b><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>Questions About Your Savings and Investments</span></b></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal style='text-align:justify'><b><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>Not counting your home, about how much are all o</span></b><b><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>f </span></b><b><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>your assets (your savings and investments)</span></b><b><span style='font-size:12.0pt; font-family:"Times New Roman",serif'> </span></b><b><span style='font-size: 12.0pt;font-family:"Times New Roman",serif'>worth?</span></b><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> ( check one)</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>O [Less than $20,000] O [$20</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>,</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>000 -$29,999 ] O [$30,000 -$49</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>,</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>999] O [More than $50</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>,</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>000]</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal style='text-align:justify'><b><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>Drafting Note:</span></b><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> Companies may choose the asset ranges to put in the brackets to fit its suitability</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> </span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>standards.</span></p> <p class=MsoNormal style='text-align:justify'><b><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>Do you expect the value of your assets to change over the next ten</span></b><b><span style='font-size:12.0pt;font-family: "Times New Roman",serif'> </span></b><b><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>years?</span></b><span style='font-size: 12.0pt;font-family:"Times New Roman",serif'> (check one)</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>O No O Yes</span><span style='font-size: 12.0pt;font-family:"Times New Roman",serif'>,</span><span style='font-size: 12.0pt;font-family:"Times New Roman",serif'> expect to increase O Yes, expect to decrease</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal style='text-align:justify'><i><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>If</span></i><i><span style='font-size: 12.0pt;font-family:"Times New Roman",serif'> y</span></i><i><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>ou're buying this [policy</span></i><i><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>]</span></i><i><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> [certificate</span></i><i><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>]</span></i><i><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> [rider</span></i><i><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>]</span></i><i><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> to protect your assets and your assets are less than</span></i><i><span style='font-size:12.0pt; font-family:"Times New Roman",serif'> </span></i><i><span style='font-size: 12.0pt;font-family:"Times New Roman",serif'>$50,000</span></i><i><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>,</span></i><i><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> experts suggest </span></i><i><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>y</span></i><i><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>ou think about other wa</span></i><i><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>y</span></i><i><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>s to pa</span></i><i><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>y</span></i><i><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> for </span></i><i><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>y</span></i><i><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>our long-term care.</span></i></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal align=center style='text-align:center'><b><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>Disclosure Statement</span></b></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> <table class=MsoTableSimple1 border=1 cellspacing=0 cellpadding=0 style='border-collapse:collapse;border:none'> <tr> <td width=650 valign=top style='width:487.2pt;border:solid black 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>O</span><span style='font-size:12.0pt; font-family:"Times New Roman",serif'> The answers to the questions above describe my financial situation.</span></p> <p class=MsoNormal style='text-align:justify'><b><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>Or</span></b></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>O</span><span style='font-size:12.0pt; font-family:"Times New Roman",serif'> I choose not to complete this information. (Check one.)</span></p> </td> </tr> </table> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> <table class=MsoTableSimple1 border=1 cellspacing=0 cellpadding=0 style='border-collapse:collapse;border:none'> <tr> <td width=650 valign=top style='width:487.2pt;border:solid black 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>O</span><span style='font-size:12.0pt; font-family:"Times New Roman",serif'> I agree that the company and/or its agent (below) has reviewed this worksheet with me including the premium, premium increase history and potential for premium increases in the future. I understand the information contained in this worksheet. (This box must be checked.)</span></p> <p class=MsoNormal style='text-align:justify'><b><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>Drafting Note:</span></b><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> For direct mail situations, the lead sentence should be changed to &quot;I agree that I have reviewed this worksheet including the premium...&quot;</span></p> </td> </tr> </table> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>Signed</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>________________________________________</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (Applicant)&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (Date)</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>[</span><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>O</span><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>] I explained to the applicant the importance of answering these questions.</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>Signed: ________________________________________</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (Agent)&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (Date)</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>Agent's Printed Name: _____________________________]</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>[In order for us to process your application, please return this signed worksheet to [name of</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> </span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>company], along with your application.]</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>[My agent has advised me that this long-term care insurance [policy] [certificate] [rider]</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> </span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>does not seem to be suitable for me. However, I still want the company to consider my</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> </span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>application.</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>Signed:</span><span style='font-size:12.0pt; font-family:"Times New Roman",serif'> _____________________________________</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>.]</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (Applicant)&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (Date)</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal style='text-align:justify'><b><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>Drafting Note:</span></b><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> Choose the appropriate sentences depending on whether this is a direct</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> </span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>mail or agent sale.</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>Someone from the company may contact you to discuss your answers and the suitability of</span><span style='font-size: 12.0pt;font-family:"Times New Roman",serif'> </span><span style='font-size: 12.0pt;font-family:"Times New Roman",serif'>this [policy] [ce</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>r</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>tificate] [rider] for</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> y</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>ou.</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> <p class=MsoNormal style='text-align:justify'><b><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>Drafting Note:</span></b><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> When the Long-Term Care Insurance Personal Worksheet is fu</span><span style='font-size: 12.0pt;font-family:"Times New Roman",serif'>r</span><span style='font-size: 12.0pt;font-family:"Times New Roman",serif'>nished to</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> </span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>employees and their spouses under employer group policies, the text from the heading</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> </span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>&quot;Disclosure Statement&quot;</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'> t</span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>o the end </span><span style='font-size:12.0pt;font-family:"Times New Roman",serif'>may be removed.</span></p> <p class=MsoNormal style='text-align:justify'><span style='font-size:12.0pt; font-family:"Times New Roman",serif'>&nbsp;</span></p> </div> </body> </html>