Appendix D

LONG-TERM CARE INSURANCE SUITABILITY LETTER Dear [Applicant] Your recent application for long-term care insurance included a personal worksheet which asked questions about your finances and your reasons for buying long-term care insurance. For your protection, state law requires us to consider this information when we review your application, to avoid selling a policy to those who may not need coverage. [Your answers indicate that long-term care insurance may not meet your financial needs. We suggest that you review the information provided along with your application, including the booklet "Shopper's Guide to Long-Term Care Insurance" and the page titled "Things You Should Know Before Buying Long-Term Care Insurance." Your state insurance department also has information about long-term care insurance and may be able to refer you to a counselor free of charge who can help you decide whether to buy this policy.] [You chose not to provide any financial information for us to review.] We have suspended our final review of your application. If, after careful consideration, you still believe this policy is what you want, check the appropriate box below and return this letter to us within the next 60 days. We will then continue reviewing your application and issue a policy if you meet our medical standards. If we do not hear from you within the next 60 days, we will close your file and not issue you a policy. You should understand that you will not have any coverage until we hear back from you, approve your application and issue you a policy. Please check one box and return in the enclosed envelope. ___ Yes, [although my worksheet indicates that long-term care insurance may not be a suitable purchase,] I wish to purchase this coverage. Please resume review of my application. ___ No, I have decided not to buy a policy at this time. Signed: _________________________________ Applicant Date: __________________________ [1-1-99; 13.10.15.52 NMAC - Rn, 13 NMAC 10.15.49, 1-1-04] 13.10.15 NMAC 31 13.10.15.53 APPENDIX E POTENTIAL RATE INCREASE DISCLOSURE FORM 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. Insurer 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 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 (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 a 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 that your premiums will not increase. (Subject to state law minimum standards.) • Exercise your nonforfeiture option if purchased. (This optionis available for purchase for additioonal premium.) • Exercise your contingent nonforfeiture rights* ( This option may be available if you do not purchase a separate nonforfeiture option.) * 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 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 13.10.15 NMAC 32 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 received 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.) Contingent Nonforfeiture Cumulative Premium Increase over Initial Premium That qualifies for Contingent Nonforfeiture (Percentage increase is cumulative from the 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% 13.10.15 NMAC 33 82 18% 83 17% 84 16% 85 15% 86 14% 87 13% 88 12% 89 11% 90 and over 10%