N.D. Admin. Code tit. 45, art. 45-06, ch. 45-06-05.1, app B
Long-Term Care Insurance Personal Worksheet
This worksheet will help you understand some important information about this type of insurance. State law requires companies issuing this [policy] [certificate] [rider] to give you some important facts about premiums and premium increases and to ask you some important questions to help you and the company decide if you should buy this [policy] [certificate] [rider]. Long-term care insurance can be expensive and it may not be right for everyone.
Premium Information
The premium for the coverage you are considering will be [$ ______ per [insert payment interval]
or a total of [$ _____ per year] [a one-time single premium of $ ______ .]
The premium quoted in this worksheet is not guaranteed and may change during the underwriting process and in the future while this [policy] [certificate] [rider] is in force.
Type of Policy and The Company's Right to Increase Premiums on the Coverage You Choose:
[Noncancellable - The company cannot increase your premiums on this [policy] [certificate] [rider].]
[Guaranteed renewable - The company can increase your premiums on this [policy] [certificate] [rider] in the future if it increases the premiums for all [policies] [certificates] [riders] like yours in this state.]
[Paid-up - This [policy] [certificate] [rider] will be paid-up after you have paid all of the premiums specified in your [policy] [certificate] [rider].]
Premium Increase History
[Name of company] has sold long-term care insurance since [year] and has sold this [policy] [certificate] [rider] since [year].
[The company has never increased its premiums for any long-term care [policy] [certificate] [rider] it has sold in this state or any other state.]
[The company has not increased its premiums for this [policy] [certificate] [rider] or similar [policies] [certificates] [riders] in this state or any other state in the last 10 years.]
Questions About Your Income
You do not have to answer the questions that follow. They are intended to make sure you have thought about how you'll pay premiums and the cost of care your insurance does not cover. If you do not want to answer these questions, you should understand that the company might refuse to insure you.
What resources will you use to pay your premium?
Current income from employment Current income from investments Other current income Savings Sell investments Sell other assets Money from my family Other
If you will be paying premiums with money received only from your own income, a rule of thumb is that you may not be able to afford this [policy] [certificate] [rider] if the premiums will be more than 7% of your income.
Could you afford to keep this [policy] [certificate] [rider] if your spouse or partner dies first?
Yes No Had not thought about itDo not know Does not apply
What would you do if the premiums went up, for example, by 50%?
Pay the higher premium Call the company/agentReduce benefits
Drop the [policy] [certificate] [rider]Do not know
What is your household annual income from all sources? (check one)
[Less than $10,000][$10,000-$19,999] [$20,000-$29,999] [$30,000-$50,000] [More than $50,000]
Do you expect your income to change over the next 10 years? (check one)
No Yes, expect increaseYes, expect decrease
Yes No Do not know
Will you buy inflation protection? (check one)
Yes No
Inflation may increase the cost of long-term care in the future.
If you do not buy inflation protection, how will you pay for the difference between future costs and your daily benefit amount?
From my incomeFrom savingsFrom investments Sell other assets Money from my family Other
The national average annual cost of long-term care in [insert year] was [insert $ amount], but this figure varies across the country. In 10 years the national average annual cost would be about [insert $ amount] if costs increase 5% annually.
What [elimination period] [waiting period] [cash deductible] are you considering?
[Number of days _______ in [elimination period] [waiting period]
Approximate cost of care for that period: $ ________
($xxx per day times number of days in [elimination period] [waiting period], where "xxx" represents the most recent estimate of the national daily average cost of long-term care)]
[Cash Deductible $ _______ ]
How are you planning to pay for your care during the [elimination period] [waiting period] [deductible period]? (check all that apply)
From my incomeFrom my savings/investments My family will pay
Questions About Your Savings and Investments
Not counting your home, about how much are all of your assets (your savings and investments) worth? (check one)
[Less than $20,000] [$20,000-$29,999] [$30,000-$50,000] [More than $50,000]
Do you expect your assets to change over the next 10 years? (check one)
No Yes, expect to increaseYes, expect to decrease
If you are buying this [policy] [certificate] [rider] to protect your assets and your assets are less than $50,000, experts suggest you think about other ways to pay for your long-term care.
Disclosure Statement
The answers to the questions above describe my financial situation. Or I choose not to complete this information. (Check one.) |
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.) |
Signed: __________________________ ____________________________
(Applicant) (Date)
[I explained to the applicant the importance of completing this information.
Signed: __________________________ ____________________________
(Agent)(Date)
Agent's Printed Name: ]
[In order for us to process your application, please return this signed worksheet to [name of company], along with your application.]
[My agent has advised me that this long-term care insurance [policy] [certificate] [rider] does not seem to be suitable for me. However, I still want the company to consider my application.]
Signed: __________________________ ____________________________
(Applicant) (Date)
Someone from the company may contact you to discuss your answers and the suitability of this [policy] [certificate] [rider] for you.
N.D. Admin Code tit. 45, art. 45-06, ch. 45-06-05.1, app B