Exhibit F - Long-Term Care Insurance Personal Worksheet

Current through Register Vol. 46, No. 15, April 8, 2022

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.

The company will ask you to fill out this worksheet to help you and the company decide if you should buy this policy. By State law, the insurance company must fill out part of the information on this worksheet.

Premium Information

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: ______________________

[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 10 years.] [The company has raised its premium rates on this policy form or similar policy forms in the last 10 years. Following is a summary of the rate increases.]

[The issuer shall list each premium increase it has instituted on this or similar policy forms in this State or any other state during the last 10 years. The list shall provide the policy form, the calendar years the form was available for sale, and the calendar year and the amount (percentage) of each increase.]

[The insurer shall provide minimum and maximum percentages if the rate increase is variable by rating characteristics. The insurer may provide, in a fair manner, additional explanatory information as appropriate.]

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 were raised substantially?]

What is your annual income? (check one)

Under $10,000




Over $50,000

How do you expect your income to change over the next 10 years? (check one)

No change



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)



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

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



Over $50,000

How do you expect your assets to change over the next ten years? (check one)

Stay about the same



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

Click here to view image

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.]


Amended at 32 Ill. Reg. 7600, effective May 5, 2008 Amended at 42 Ill. Reg. 4867, effective 2/27/2018

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