Policy Form Number(s)

The premium for the coverage you are considering will be

[$

per month, or

$

per year,] [a one-time single premium of

$

]

Type of Policy (noncancellable/guaranteed renewable):

The Company's Right to Increase Premiums:

How will you pay each year's premium?

 From my Income

 From my Savings/Investments

 My Family will Pay

[ Have you considered whether you could afford to keep this policy if the premiums were raised substantially?]

What is your annual income?  (check one)

 Under $10,000

 $[10-20,000]

 $[20-30,000]

 $[30-50,000]

 Over $50,000

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 day _____ 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

Not counting your home, about how much are all of your assets (your savings and investments) worth?  (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.

  The answers to the questions above describe my financial situation

Or

  I choose not to complete this information

(Check one.)

  I acknowledge that the carrier and/or its agent (below) has reviewed this form with me

including the premium, premium rate increase history and potential for premium increases in the future.  [For direct mail situations, use the following:  I acknowledge that I have reviewed this form including their premium, premium rate increase history and potential for premium increases in the future.]  I understand the above disclosures. I understand that the rates for this policy may increase in the future. (This box must be checked).

Signed:

(Applicant)

(Date)

[  I explained to the applicant the importance of completing this information.

Signed:

(Insurance Producer)

(Date)

Insurance Producer's Printed Name:

]

[Choose the appropriate sentences depending on whether this is a direct mail or insurance producer sale.]

[In order for us to process your application, please return this signed statement to [name of company], along with your application.]

[My insurance producer 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)

The company may contact you to verify your answers.

[When the Long-Term Care Insurance Personal Worksheet is furnished to employees and their spouses under employer group policies, the text from the heading "Disclosure Statement" to the end of the page may be removed.]