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)
Ins 3.46 APPENDIX 3
THINGS YOU SHOULD KNOW BEFORE YOU BUY LONG-TERM CARE INSURANCE
