Form LTC-F "Long-Term Care Insurance Potential Rate Increase Disclosure Form" - Missouri

What Is Form LTC-F?

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-F 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-F "Long-Term Care Insurance Potential Rate Increase Disclosure Form" - Missouri

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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:
Long-Term Care Insurance
Potential Rate Increase Disclosure Form
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][approved]
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 product
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.)
Turn the Page
* Contingent Nonforfeiture
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:
Long-Term Care Insurance
Potential Rate Increase Disclosure Form
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][approved]
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 product
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.)
Turn the Page
* 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 one hundred-twenty (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).
• Your “paid-up” policy benefits are $10,000 (provided you have at least $10,000
of benefits remaining under your policy.)
Turn the Page
Contingent Nonforfeiture
Cumulative Premium Increase over Initial Premium
That Qualifies for Contingent Nonforfeiture
(Percentage increase is cumulative from date of original issue. It does NOT represent a one-time
increase.)
Issue Age
Percent Increase Over Initial Premium
29 and under
200%
30–34
190%
35–39
170%
40–44
150%
45–49
130%
50–54
110%
55–59
90%
60
70%
61
66%
62
62%
63
58%
64
54%
65
50%
66
48%
67
46%
68
44%
69
42%
70
40%
71
38%
72
36%
73
34%
74
32%
75
30%
76
28%
77
26%
78
24%
79
22%
80
20%
81
19%
82
18%
83
17%
84
16%
85
15%
86
14%
87
13%
88
12%
89
11%
90 and over
10%
[The following contingent nonforfeiture disclosure need only be included for those
limited pay policies to which Sections (26)(D)4 and (26)(D)6 of the regulation are
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;
Triggers for a Substantial Premium Increase
Percent Increase
Over
Issue Age
Initial Premium
Under 65
50%
65-80
30%
Over 80
10%
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.
If you purchased lifetime benefits, only the daily benefit amounts you purchased will
be adjusted by the applicable ratio.
Example:
You bought the policy at age 65 with an annual premium payable for 10
years.
In the sixth year, you receive a rate increase of 35% and you decide to stop
paying premiums.
Because you have already paid 50% of your total premium payments and
that is more than the 40% ratio, your “paid-up” policy benefits are .45 (.90
times .50) times the total benefit amount that was in effect when you stopped
paying your premiums. If you purchased inflation protection, it will not
continue to apply to the benefits in the reduced “paid-up” policy.]
Form LTC-F
(Rev 11/15/2007)
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