What is your annual income? (check one)
⍽ Under $10,000 ⍽ $10,000-20,000 ⍽ $20,000-30,000 ⍽ $30,000-50,000 ⍽ Over $50,000
Note: The insurer may choose the numbers to put in the brackets to fit its suitability standards.
How do you expect your income to change over the next 10 years? (check one)
⍽ No change ⍽ Increase
⍽ Decrease
If you will be paying premiums with money received only from your own income, a rule of thumb is that you may not be able to afford this policy if the premiums will be more than 7% of your income.
Will you buy inflation protection? (check one) ⍽ Yes ⍽ No
If not, have you considered how you will pay for the difference between future costs and your daily benefit amount?
⍽ From my Income ⍽ From my Savings \ Investments ⍽ My Family will Pay
The national average annual cost of care in [insert year] was [insert $ amount], but this figure varies across the country. In ten years the national average annual cost would be about [insert $ amount] if costs increase 5% annually.
What elimination period are you considering? Number of days _______Approximate cost $ _______ for that period of care.
How are you planning to pay for your care during the elimination period? (check one)
⍽ From my Income ⍽ From my Savings \ Investments ⍽ My Family will Pay
QUESTIONS RELATED TO YOUR SAVINGS AND INVESTMENTS
Not counting your home, what is the approximate value of all of your assets (savings and investments)? (check one)
⍽ Under $20,000 ⍽ $20,000-$30,000 ⍽ $30,000-$50,000 ⍽ Over $50,000
How do you expect your assets to change over the next ten years? (check one)
⍽ Stay about the same ⍽ Increase ⍽ Decrease
If you are buying this policy to protect your assets and your assets are less than $30,000, you may wish to consider other options for financing your long-term care.
Signed:_____________________________ ______________
(Applicant) (Date)
(I explained to the applicant the importance of completing this information.)
Signed:____________________________ _______________
(Agent) (Date)
Agent's Printed Name:_______________________________
Note: In order for us to process your application, please return this signed statement to [name of company], along with your application.
[My agent has advised me that this policy does not appear to be suitable for me. However, I still want the company to consider my application.]
Signed:_____________________________ _______________
(Applicant) (Date)
Ins 3.46 APPENDIX 3
THINGS YOU SHOULD KNOW BEFORE YOU BUY LONG-TERM CARE INSURANCE
[Note: For single premium policies, delete the above bullet; for noncancellable policies, delete the second sentence only.]
Ins 3.46 APPENDIX 4
LONG-TERM CARE INSURANCE SUITABILITY LETTER
Dear [Applicant]:
Your recent application for [long-term care insurance] [insurance for care in a nursing home] [insurance for care at home or other community setting] included a “personal worksheet," which asked questions about your finances and your reasons for buying this coverage. For your protection, state law requires us to consider this information when we review your application, to avoid selling a policy to those who may not need coverage.
[Your answers indicate that insurance coverage you applied for may not meet your financial needs. We suggest that you review the information provided along with your application, including the booklet “Guide to Long-Term Care" and the page titled “Things You Should Know Before Buying Long-Term Care Insurance." The Wisconsin Office of the Commissioner of Insurance also has information about long-term care insurance and may be able to refer you to a county Benefit specialist or a Senior Health Insurance Information specialist free of charge who can help you decide whether to buy this policy.]
[You chose not to provide any financial information for us to review.]
Note: Choose the paragraph and bracketed sentences in that paragraph that apply.
We have suspended our final review of your application. If, after careful consideration, you still believe this policy is what you want, check the appropriate box below and return this letter to us within the next 60 days. We will then continue reviewing your application and issue a policy if you meet our medical standards.
If we do not hear from you within the next 60 days, we will close your file and not issue you a policy. You should understand that you will not have any coverage until we hear back from you, approve your application, and issue you a policy.
Please check one box and return in the enclosed envelope.
⍽ Yes, [although my worksheet indicates that nursing home only or home health care insurance only insurance may not be a suitable purchase,] I wish to purchase this coverage. Please resume review of my application.
Note: Delete the phrase in brackets if the applicant did not answer the questions about income.
⍽ No, I have decided not to buy a policy at this time.
_______________________________ __________________
(Applicant's Signature) (Date)
Please return to [insurer] at [address] by [date].
Ins 3.46 APPENDIX 5
LONG-TERM CARE INSURANCE POTENTIAL RATE INCREASE
DISCLOSURE FORM
Instructions:
This form provides information to the applicant regarding premium rate schedules, rate schedule adjustments, potential rate revisions, and policyholder options in the event of a rate increase.
Insurers shall provide all of the following information to the applicant:
1. [Premium Rate] [Premium Rate Schedules]: [Premium rate] [Premium rate schedules] that [is][are] applicable to you and that will be in effect until a request is made and [filed] for an increase [is][are] [on the application][$_____])
2. The [premium] [premium rate schedule] for this policy [will be shown on the schedule page of] [will be attached to] your policy.
3. Rate Schedule Adjustments:
The company will provide a description of when premium rate or rate schedule adjustments will be effective (e.g., next anniversary date, next billing date, etc.) (fill in the blank): __________________.
4. Potential Rate Revisions:
This policy is Guaranteed Renewable. This means that the rates for this policy may be increased in the future. Your rates can NOT be increased due to your increasing age or declining health, but your rates may go up based on the experience of all policyholders with a policy similar to yours.
If you receive a premium rate or premium rate schedule increase in the future, you will be notified of the new premium amount and you will be able to exercise at least one of the following options:
• Pay the increased premium and continue your policy in force as is.
• Reduce your policy benefits to a level such that your premiums will not increase. (Subject to state law minimum standards.)
• Exercise your nonforfeiture option if purchased. (This option is available for purchase for an additional premium.)
• Exercise your contingent nonforfeiture rights.* (This option may be available if you do not purchase a separate nonforfeiture option.)
*Contingent Nonforfeiture
If the premium rate for your policy goes up in the future and you didn't buy a nonforfeiture option, you may be eligible for contingent nonforfeiture. Here's how to tell if you are eligible:
You will keep some long-term care insurance coverage, if:
Your premium after the increase exceeds your original premium by the percentage shown (or more) in the following table and
You lapse (not pay more premiums) within 120 days of the increase.
The amount of coverage (i.e., new lifetime maximum benefit amount) you will keep will equal the total amount of premiums you've paid since your policy was first issued. If you have already received benefits under the policy, so that the remaining maximum benefit amount is less than the total amount of premiums you've paid, the amount of coverage will be that remaining amount.
Except for this reduced lifetime maximum benefit amount, all other policy benefits will remain at the levels attained at the time of the lapse and will not increase thereafter.
Should you choose this Contingent Nonforfeiture option your policy with this reduced maximum benefit amount will be considered paid up with no further premiums due.
Example:
You bought the policy at age 65 and paid the $1,000 annual premium for 10 years, so you have paid a total of $10,000 in premium.
In the eleventh year, you receive a rate increase of 50%, or $500 for a new annual premium of $1,500, and you decide to lapse the policy (not pay any more premiums).
[The following contingent nonforfeiture disclosure need only be included for those limited pay policies to which sub. (19) (j) is applicable.]
In addition to the contingent nonforfeiture benefits described above, the following reduced “paid-up" contingent nonforfeiture benefit is an option in all policies that have a fixed or limited premium payment period, even if you selected a nonforfeiture benefit when you bought your policy. If both the reduced “paid up" benefit AND the contingent benefit described above are triggered by the same rate increase, you can choose either of the two benefits.
You are eligible for the reduced “paid up" contingent nonforfeiture benefit when all three conditions shown below are met:
1. The premium you are required to pay after the increase exceeds your original premium by the same percentage or more shown in the chart below;
- See PDF for table 
2. You stop paying your premiums within 120 days of when the premium increase took effect; AND
3. The ratio of the number of months you already paid premiums is 40% or more than the number of months you originally agreed to pay.
If you exercise this option, your coverage will be converted to reduced “
paid-up" status. That means there will be no additional premiums required. Your benefits will change in the following ways:
a. The total lifetime amount of benefits your reduced paid up policy will provide can be determined by multiplying 90% of the lifetime benefit amount at the time the policy becomes paid up by the ratio of the number of months you already paid premiums to the number of months you agreed to pay them.
b. The daily benefit amounts you purchased will also be adjusted by the same ratio.
