⬜ 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.

DISCLOSURE STATEMENT

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)