<html xmlns="http://www.w3.org/1999/xhtml"><head><meta charset="UTF-8" /><title></title><meta name="Generator" content="PowerTools for Open XML" /><style>span { white-space: pre-wrap; } p.sf1594c41-b4ae-4abc-9d01-3d18b7968116P0 { margin-top: 0; margin-bottom: 0; margin-left: 0; margin-right: 0; text-indent: 0.00in; text-align: left; background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; line-height: 108%; } span.sf1594c41-b4ae-4abc-9d01-3d18b7968116000000 { font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } p.sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000001 { margin-top: 0; margin-bottom: 0; margin-left: 0; margin-right: 0; text-indent: 0.00in; text-align: center; background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; line-height: 108%; } span.sf1594c41-b4ae-4abc-9d01-3d18b7968116C0 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } 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</style></head><body><div><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000001"><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">DEPARTMENT OF LABOR AND REGULATION</span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000001"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000001"><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">DIVISION OF INSURANCE</span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000001"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000001"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000001"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000001"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000001"><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">PERSONAL WORKSHEET</span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000001"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000001"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000001"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">Chapter </span><a href="https://sdlegislature.gov/Rules?Rule=20:06:21"><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000002">20:06:21</span></a></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000001"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000001"><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">APPENDIX E</span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000001"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000001"><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">SEE: §</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000003"> </span><a href="https://sdlegislature.gov/Rules?Rule=20:06:21:53.02"><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000002">20:06:21:53.02</span></a></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000001"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000001"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000001"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000001"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000001"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000001"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000001"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000001"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000001"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000001"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000001"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000001"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000001"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000001"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000001"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000001"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000001"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000001"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000001"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000001"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">    </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000004">Source:</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> 28 SDR 157, effective May 19, 2002; 44 SDR 184, effective June 25, 2018.</span></p><h6 dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P3"><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000005"><br />&#x200e;</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000004">Long-Term Care Insurance</span></h6><h5 dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P2"><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000004">Personal Worksheet</span></h5><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000004">Drafting Note:</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> Companies shall at a minimum provide all of the information shown below and</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">in the same order. The company may include additional information related to this long-term</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">care insurance coverage in relevant and readable language. Bracketed statements indicate the</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">companies should choose the applicable statement, are allowed flexibility in inserting numerical</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">ranges, etc.</span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000004">Long-Term Care Insurance Personal Worksheet</span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">This worksheet will help you understand some important information about this type of insurance.</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> </span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">State law requires companies issuing this [policy] [certificate] [rider] to </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000004">give</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> you some important</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> </span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">facts about premiums and premium increases and to </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000004">ask</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> you some important questions to help </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">y</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">ou</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">and the company decide if you should bu</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">y</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> this [policy] [certificate] [rider]. Long-te</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">rm</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> care</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">insurance can be expensive and it may not be right for everyone.</span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000004">Premium Information</span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000004">The premium for the coverage you are considering will be</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> [$</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">____</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> per [insert payment interval</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">] </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000004">or a total of</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">[$</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">______</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> per</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> y</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">ear] [a one-time single premium of</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">$</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">_______</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">].</span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000004">The premium quoted in this worksheet is not guaranteed and may change during the</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000004"> </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000004">underwriting process and in the future while this [policy] [certificate] [rider</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000004">]</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000004"> is in force.</span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000004">Drafting Note:</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> Companies will insert payment interval - monthly, quarterl</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">y</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">, etc. and the</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">appropriate dollar amount.</span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000004">Type of Policy &amp; The Company's Right to Increase Premiums on the Coverage You Choose:</span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">[Noncancellable - The company </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000004">cannot</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> increase your premiums on this [policy] </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">[</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">certificate] [rider]].</span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">[Guaranteed renewable - The company </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000004">can</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> increase your premiums on this [policy]</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">[certificate] [rider] in the future if it increases the premiums for all [policies] [certificates] [riders]</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">like yours in this state.]</span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">[Paid-up - This [policy] </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">[</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">certificate] [rider] will be paid-up after </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">y</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">ou have paid all of the premiums</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">specified in your [policy</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">]</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> [certificate] [rider]].</span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000004">Drafting Note:</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> Companies will insert the appropriate policy type and the associated bracketed</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">statement. Premium guarantees shall not be shown on this form.</span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000004">P</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000004">remium Increase History</span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">[Name of</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">company</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">] </span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">has sold </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">l</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">ong-tenn care insurance since [yea</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">r]</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> and has sold this [policy]</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">[certificate] [rider] since [year].</span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">[The company has never increased its premiums for any long-te</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">rm</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> care [policy] [certificate] [rider]</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">it has sold in this state or any other state.]</span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">[The company has not increased its premiums for this [policy] [certificate] [rider] or similar</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">[policies] [certificates] [riders] in this state or any other state in the last 10 years.]</span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">[The company has increased its premiums on this [policy] [certificate] [rider] or similar [policies]</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">[certificates] [riders] in the last 10 years. A summary of those premium increases follows.</span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">Drafting Note:</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> If the summary of premium increases is extensive, the company may disclose the</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">required premium increase history via an addendum attached to this worksheet. The company</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">may substitute the language below for the last sentence in the paragraph above and include the</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">full summary as an attachment to this worksheet.</span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">"Over the past 3 </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">y</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">ears</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">,</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> the company has increased premiums by</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> ___</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">%."</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> </span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">A summary of </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">p</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">remium</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> </span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">increases in the last 10 </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">y</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">ears is attached to this worksheet".</span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">Companies that have increased premiums b</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">y</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> 30% or more in the last ten </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">y</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">ears must include the</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">following statement: "There was a 30% or greater premium</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">increase in [insert year]." "A summary of premium increases in the last 10 years is attached to</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">this worksheet."</span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000004">Questions About Your Income</span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">You do </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000004">not</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> have to answer the questions that follow. They are intended to make sure you have thought</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">about how you'll pay premiums and the cost of care your insurance does not cover. If you do not want</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">to answer these questions</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">,</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> you should understand that the company might refuse to insure you.</span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000004">What resources will you use to pay your premium?</span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> Current income from employment O Current income from investments</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">O Other current</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">income</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">O Savings O Sell investments O Sell other assets</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">O Money from my family O Other</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">____</span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000007">l</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000007">f y</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000007">ou </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000007">w</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000007">ill be paying premiums with mone</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000007">y</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000007"> received only f</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000007">r</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000007">om your own income, a rule o</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000007">f </span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000007">thumb is that </span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000007">you </span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000007">may not be able to </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000007">af</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000007">ford this [policy</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000007">]</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000007"> [certificate</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000007">]</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000007"> [</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000007">ri</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000007">der</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000007">]</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000007"> if</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000007"> </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000007">the premiums will be more than 7% o</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000007">f y</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000007">our</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000007"> </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000007">income.</span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000004">Could you afford to keep this [policy] [certificate] [rider] if your spouse or partner dies first?</span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">O Yes</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> </span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> O No</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> </span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> O Had not thought about it</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> </span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> O Do not know </span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">O Does not apply</span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000004">[</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000004">What would you do if the premiums went up, for example, by 50%</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000004">?</span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">O Pay the higher premium </span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">O Call the company/agent</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> </span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> O Reduce benefits</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> </span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> O Drop the </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000004">[policy</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000004">] </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000004">[certificate</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000004">]</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000004"> </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000004">[</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000004">rider</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000004">]</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> </span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> O Do not know]</span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000004">Drafting Note:</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> The company is not required to use the bracketed question above if the coverage</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">is fully paid up or is noncancellable.</span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000004">What is your household annual income from all sources?</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> (check one)</span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">O [Less than $10,000] O $[10,000-19,999] O $[20</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">,</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">000-29,999] O $</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">[</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">30,000-50</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">,</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">000] O [More</span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">than $50</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">,</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">000]</span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000004">Drafting Note:</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> The companies may choose the income ranges to put in the brackets to fit its</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">suitability standards.</span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000004">Do </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000004">y</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000004">ou expect your income to change over the next 10 </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000004">y</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000004">ears?</span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">(check one)</span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">O No O Yes, expect increase O Yes, expect decrease</span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000004">If you plan to pay premiums from your income, have you thought about how a change in</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000004"> </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000004">your income would affect your ability to continue to pay the premium?</span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">O Yes O No O Do not know</span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000004">Will you buy inflation protection?</span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">(check one) O Yes O No</span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000007">Inflation may increase the cost o</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000007">f </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000007">long-term care in the f</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000007">u</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000007">ture.</span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000004">If you do not buy inflation protection, how will you pay for the difference between future costs</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000004"> </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000004">and your daily benefit amount?</span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">O From my income O From savings O From investments O Sell other assets O Money from my famil</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">y</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> O</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">Other</span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000007">The national average annual cost of</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000007"> l</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000007">ong-term care in [insert vear</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000007">]</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000007">·was [insert</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000007"> </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000007">$ amount</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000007">]</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000007">, but this figure</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000007"> </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000007">varies across the countr</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000007">y</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000007">. In ten </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000007">y</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000007">ears the national average annual cost would be about [insert</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000007"> </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000007">$ amount</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000007">]</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000007"> i</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000007">f </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000007">costs increase 5% annually.</span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">Drafting Note: The projected cost can be based on federal estimates in a current year. This figure</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">should also be used when calculating the cost of long-term care in the "approximate cost $</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">____ </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">for that period of care" question found below. In the above statement, the second figure will</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">equal 163% of the first figure.</span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">What [elimination period] </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">[</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">waiting period] [cash deductible] are you considering?</span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">[Number of days</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> _____</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> in [elimination period][ waiting period]</span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">Approximate cost of care for this period:</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">$</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">______</span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">($xxx per day times number of days in [elimination period] [waiting period]</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">,</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> where "xxx"</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">represents the most recent estimate of the national daily average cost of long-te</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">rm</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> care)]</span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">[Cash Deductible</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">$</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">_______</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">.</span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000004">How do you plan to pay for your care during the [elimination period] [waiting period]</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000004"> </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000004">[deductible period]?</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> (check all that apply)</span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">O From m</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">y</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> income O From my savings/investments O My family will pay</span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000004">Questions About Your Savings and Investments</span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000004">Not counting your home, about how much are all o</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000004">f </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000004">your assets (your savings and investments)</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000004"> </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000004">worth?</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> ( check one)</span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">O [Less than $20,000] O [$20</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">,</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">000 -$29,999 ] O [$30,000 -$49</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">,</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">999] O [More than $50</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">,</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">000]</span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000004">Drafting Note:</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> Companies may choose the asset ranges to put in the brackets to fit its suitability</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">standards.</span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000004">Do you expect the value of your assets to change over the next ten</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000004"> </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000004">years?</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> (check one)</span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">O No O Yes</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">,</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> expect to increase O Yes, expect to decrease</span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000007">If</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000007"> y</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000007">ou're buying this [policy</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000007">]</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000007"> [certificate</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000007">]</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000007"> [rider</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000007">]</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000007"> to protect your assets and your assets are less than</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000007"> </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000007">$50,000</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000007">,</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000007"> experts suggest </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000007">y</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000007">ou think about other wa</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000007">y</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000007">s to pa</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000007">y</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000007"> for </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000007">y</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000007">our long-term care.</span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000001"><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000004">Disclosure Statement</span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><div align="left"><table dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000008"><tr><td class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000009"><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">O</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> The answers to the questions above describe my financial situation.</span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000004">Or</span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">O</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> I choose not to complete this information. (Check one.)</span></p></td></tr></table></div><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><div align="left"><table dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000008"><tr><td class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000009"><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">O</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> 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 dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000004">Drafting Note:</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> For direct mail situations, the lead sentence should be changed to "I agree that I have reviewed this worksheet including the premium..."</span></p></td></tr></table></div><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">Signed</span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">________________________________________</span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">    (Applicant)                        (Date)</span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">[</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">O</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">] I explained to the applicant the importance of answering these questions.</span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">Signed: ________________________________________</span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">            (Agent)                            (Date)</span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">Agent's Printed Name: _____________________________]</span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">[In order for us to process your application, please return this signed worksheet to [name of</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">company], along with your application.]</span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">[My agent has advised me that this long-term care insurance [policy] [certificate] [rider]</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">does not seem to be suitable for me. However, I still want the company to consider my</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">application.</span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">Signed:</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> _____________________________________</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">.]</span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">            (Applicant)                    (Date)</span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000004">Drafting Note:</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> Choose the appropriate sentences depending on whether this is a direct</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">mail or agent sale.</span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">Someone from the company may contact you to discuss your answers and the suitability of</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">this [policy] [ce</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">r</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">tificate] [rider] for</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> y</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">ou.</span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0-000004">Drafting Note:</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> When the Long-Term Care Insurance Personal Worksheet is fu</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">r</span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">nished to</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">employees and their spouses under employer group policies, the text from the heading</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">"Disclosure Statement"</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0"> t</span><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">o the end </span><span class="sf1594c41-b4ae-4abc-9d01-3d18b7968116C0">may be removed.</span></p><p dir="ltr" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116P0-000006"><span xml:space="preserve" class="sf1594c41-b4ae-4abc-9d01-3d18b7968116000000"> </span></p></div></body></html>