Form LTC-B "Long-Term Care Insurance Personal Worksheet" - Missouri

What Is Form LTC-B?

This is a legal form that was released by the Missouri Department of Commerce and Insurance - a government authority operating within Missouri. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on November 15, 2007;
  • The latest edition provided by the Missouri Department of Commerce and Insurance;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form LTC-B by clicking the link below or browse more documents and templates provided by the Missouri Department of Commerce and Insurance.

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Download Form LTC-B "Long-Term Care Insurance Personal Worksheet" - Missouri

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Long-Term Care Insurance
Personal Worksheet
People buy long-term care insurance for many reasons. Some don’t want to use their own
assets to pay for long-term care. Some buy insurance to make sure they can choose the
type of care they get. Others don’t want their family to have to pay for care or don’t want
to go on Medicaid. But long-term care insurance may be expensive, and may not be right
for everyone.
By state law, the insurance company must fill out part of the information on this
worksheet and ask you to fill out the rest to help you and the company decide if you
should buy this policy.
Premium Information
Policy Form Numbers _____________________
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:
_______________________________________
[The company cannot raise your rates on this policy.] [The company has a right to
increase premiums on this policy form in the future, provided it raises rates for all
policies in the same class in this state.] [Insurers shall use appropriate bracketed
statement. Rate guarantees shall not be shown on this form.]
Rate Increase History The company has sold long-term care insurance since [year] and
has sold this policy since [year]. [The company has never raised its rates for any long-
term care policy it has sold in this state or any other state.] [The company has not raised
its rates for this policy form or similar policy forms in this state or any other state in the
last ten (10) years.] [The company has raised its premium rates on this policy form or
similar policy forms in the last ten (10) years. Following is a summary of the rate
increases.]
Questions Related to Your Income
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
went up, for example, by 20%?]
(This is not required if the policy is fully paid up or is a noncancellable policy.)
What is your annual income? (check one)
Under $10,000
$[10–20,000]
$[20–30,000]
$[30–50,000]
Over $50,000
Long-Term Care Insurance
Personal Worksheet
People buy long-term care insurance for many reasons. Some don’t want to use their own
assets to pay for long-term care. Some buy insurance to make sure they can choose the
type of care they get. Others don’t want their family to have to pay for care or don’t want
to go on Medicaid. But long-term care insurance may be expensive, and may not be right
for everyone.
By state law, the insurance company must fill out part of the information on this
worksheet and ask you to fill out the rest to help you and the company decide if you
should buy this policy.
Premium Information
Policy Form Numbers _____________________
The premium for the coverage you are considering will be [$_________ per month, or
$_______ per year,] [a one-time single premium of $____________.]
Type
of
Policy
(noncancellable/guaranteed
renewable):_________________________________
The
Company’s
Right
to
Increase
Premiums:
_______________________________________
[The company cannot raise your rates on this policy.] [The company has a right to
increase premiums on this policy form in the future, provided it raises rates for all
policies in the same class in this state.] [Insurers shall use appropriate bracketed
statement. Rate guarantees shall not be shown on this form.]
Rate Increase History The company has sold long-term care insurance since [year] and
has sold this policy since [year]. [The company has never raised its rates for any long-
term care policy it has sold in this state or any other state.] [The company has not raised
its rates for this policy form or similar policy forms in this state or any other state in the
last ten (10) years.] [The company has raised its premium rates on this policy form or
similar policy forms in the last ten (10) years. Following is a summary of the rate
increases.]
Questions Related to Your Income
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
went up, for example, by 20%?]
(This is not required if the policy is fully paid up or is a noncancellable policy.)
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 ten (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 (10) 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, 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 (10) 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
~ 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 producer (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 the 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: __________________________________________
______________________________
(Producer)
(Date)
Producer’s Printed Name: ______________________________________ ]
[In order for us to process your application, please return this signed statement to [name
of company], along with your application.]
[My producer has advised me that this policy does not seem to be suitable for me.
However, I still want the company to consider my application.]
(Insurers: Choose the appropriate sentences depending on whether this is a direct mail or
producer sale.)
Signed: __________________________________________
______________________________
(Applicant)
(Date)
The company may contact you to verify your answers.
LTC-B
(Rev. 11/15/2007)
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