<html> <head> <title>Rule 20:06:21:0I Potential Rate Increase Disclosure Form.</title> <META NAME="Keywords" Content="Administrative Rules 20:06:21:0I"> <META NAME="Description" Content="Administrative Rules 20:06:21:0I Potential Rate Increase Disclosure Form."> <meta http-equiv=Content-Type content="text/html; charset=windows-1252"> <meta name=Generator content="Microsoft Word 15 (filtered)"> <style> <!-- /* Font Definitions */ @font-face {font-family:Wingdings; panose-1:5 0 0 0 0 0 0 0 0 0;} @font-face {font-family:"Cambria Math"; panose-1:2 4 5 3 5 4 6 3 2 4;} /* Style Definitions */ p.MsoNormal, li.MsoNormal, div.MsoNormal {margin:0in; margin-bottom:.0001pt; font-size:12.0pt; font-family:"Times New Roman",serif; color:black;} h1 {mso-style-link:"Heading 1 Char"; margin:0in; margin-bottom:.0001pt; text-align:justify; page-break-after:avoid; font-size:12.0pt; font-family:"Times New Roman",serif; color:black; font-weight:normal;} h5 {mso-style-link:"Heading 5 Char"; margin:0in; margin-bottom:.0001pt; text-align:center; page-break-after:avoid; font-size:12.0pt; font-family:"Times New Roman",serif; color:black;} a:link, span.MsoHyperlink {color:blue; text-decoration:underline;} a:visited, span.MsoHyperlinkFollowed {color:purple; text-decoration:underline;} span.Heading1Char {mso-style-name:"Heading 1 Char"; mso-style-link:"Heading 1";} span.Heading5Char {mso-style-name:"Heading 5 Char"; mso-style-link:"Heading 5"; font-weight:bold;} .MsoChpDefault {font-size:10.0pt; color:black;} @page WordSection1 {size:8.5in 11.0in; margin:1.0in 1.25in 1.0in 1.25in;} div.WordSection1 {page:WordSection1;} /* List Definitions */ ol {margin-bottom:0in;} ul {margin-bottom:0in;} --> </style> </head> <body lang=EN-US link=blue vlink=purple> <div class=WordSection1> <p class=MsoNormal style='text-align:justify'>&nbsp;</p> <p class=MsoNormal style='text-align:justify'>&nbsp;</p> <p class=MsoNormal>&nbsp;</p> <p class=MsoNormal>&nbsp;</p> <p class=MsoNormal>&nbsp;</p> <p class=MsoNormal>&nbsp;</p> <p class=MsoNormal>&nbsp;</p> <p class=MsoNormal>&nbsp;</p> <p class=MsoNormal>&nbsp;</p> <p class=MsoNormal>&nbsp;</p> <p class=MsoNormal>&nbsp;</p> <p class=MsoNormal>&nbsp;</p> <p class=MsoNormal>&nbsp;</p> <p class=MsoNormal>&nbsp;</p> <p class=MsoNormal align=center style='text-align:center'>DEPARTMENT OF LABOR AND REGULATION</p> <p class=MsoNormal align=center style='text-align:center'>&nbsp;</p> <p class=MsoNormal align=center style='text-align:center'>DIVISION OF INSURANCE</p> <p class=MsoNormal align=center style='text-align:center'>&nbsp;</p> <p class=MsoNormal align=center style='text-align:center'>&nbsp;</p> <p class=MsoNormal align=center style='text-align:center'>&nbsp;</p> <p class=MsoNormal align=center style='text-align:center'>&nbsp;</p> <p class=MsoNormal align=center style='text-align:center'>POTENTIAL RATE INCREASE DISCLOSURE FORM</p> <p class=MsoNormal align=center style='text-align:center'>&nbsp;</p> <p class=MsoNormal align=center style='text-align:center'>&nbsp;</p> <p class=MsoNormal align=center style='text-align:center'>Chapter 20:06:21</p> <p class=MsoNormal align=center style='text-align:center'>&nbsp;</p> <p class=MsoNormal align=center style='text-align:center'>APPENDIX I</p> <p class=MsoNormal align=center style='text-align:center'>&nbsp;</p> <p class=MsoNormal align=center style='text-align:center'>SEE: &#167; 20:06:21:60</p> <p class=MsoNormal align=center style='text-align:center'>&nbsp;</p> <p class=MsoNormal align=center style='text-align:center'>&nbsp;</p> <p class=MsoNormal align=center style='text-align:center'>&nbsp;</p> <p class=MsoNormal align=center style='text-align:center'>&nbsp;</p> <p class=MsoNormal align=center style='text-align:center'>&nbsp;</p> <p class=MsoNormal align=center style='text-align:center'>&nbsp;</p> <p class=MsoNormal align=center style='text-align:center'>&nbsp;</p> <p class=MsoNormal align=center style='text-align:center'>&nbsp;</p> <p class=MsoNormal align=center style='text-align:center'>&nbsp;</p> <p class=MsoNormal align=center style='text-align:center'>&nbsp;</p> <p class=MsoNormal align=center style='text-align:center'>&nbsp;</p> <p class=MsoNormal align=center style='text-align:center'>&nbsp;</p> <p class=MsoNormal align=center style='text-align:center'>&nbsp;</p> <p class=MsoNormal align=center style='text-align:center'>&nbsp;</p> <p class=MsoNormal align=center style='text-align:center'>&nbsp;</p> <p class=MsoNormal>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>Source:</b> 28 SDR 157, effective May 19, 2002; 33 SDR 230, effective July 2, 2007; 44 SDR 184, effective June 25, 2018.</p> <span style='font-size:12.0pt;font-family:"Times New Roman",serif'><br clear=all style='page-break-before:always'> </span> <p class=MsoNormal style='text-align:justify'><b><i>Instructions:</i></b><i> Insurers shall provide all of the following information to the applicant regarding premium, premium adjustments, potential premium increases, and policyholder options in the event of a premium increase except as noted below. This form does not need to be provided in the event the policy does not reserve the right to increase rates.</i></p> <p class=MsoNormal style='text-align:justify'>&nbsp;</p> <p class=MsoNormal style='text-align:justify'>As used in this Appendix:</p> <p class=MsoNormal style='text-align:justify'>&nbsp;</p> <p class=MsoNormal style='text-align:justify'>&quot;Policy,&quot; is a policy, certificate, or rider, as applicable.</p> <p class=MsoNormal style='text-align:justify'>&quot;Premium,&quot; includes premium schedules, as applicable.</p> <p class=MsoNormal style='text-align:justify'>Companies may substitute whichever term is appropriate to reflect the long-term care insurance for which the applicant is applying.</p> <p class=MsoNormal style='text-align:justify'>&nbsp;</p> <p class=MsoNormal align=center style='text-align:center'><b>Long-Term Care Insurance</b></p> <p class=MsoNormal align=center style='text-align:center'><b>Potential Premium Increase Disclosure Form</b></p> <p class=MsoNormal style='text-align:justify'>&nbsp;</p> <table class=MsoTableSimple1 border=1 cellspacing=0 cellpadding=0 style='border-collapse:collapse;border:none'> <tr> <td width=590 valign=top style='width:6.15in;border:solid black 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><b>Important Notice:</b> Your long-term care insurance company <b>may</b> increase the premium for your policy <b>every year</b>. You have certain rights and it's important that you understand them before you buy a long-term care insurance policy. Please read this information and be sure you understand it before you buy a policy.</p> </td> </tr> </table> <p class=MsoNormal style='text-align:justify'>&nbsp;</p> <p class=MsoNormal style='text-align:justify'><b><i>This policy is guaranteed renewable.</i></b><i> Companies can increase the premiums for</i><i> guaranteed renewable policies in the future. The compan</i><i>y <b>cannot</b> increase your premiums</i><i> because <b>you are</b> older or <b>your</b> health declines. It can increase premiums based on the</i><i> experience of</i><i> all individuals with a</i><i> policy like yours.</i></p> <p class=MsoNormal style='text-align:justify'>&nbsp;</p> <p class=MsoNormal style='text-align:justify'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>1.</b><b>&nbsp;&nbsp;What Is Your Premium?</b></p> <p class=MsoNormal style='text-align:justify'>&nbsp;</p> <p class=MsoNormal style='margin-left:45.0pt;text-align:justify;text-indent: -45.0pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; The agent/company has quoted you a premium of [$_____] for this policy. This is not <b>a</b> final premium. The premium might change during the underwriting process or if you choose different benefits. The premium you'll be required to pay for your policy will be [shown on the schedule page of] [will be attached to] your policy.</p> <p class=MsoNormal style='text-align:justify'>&nbsp;</p> <p class=MsoNormal style='text-align:justify'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>2.</b><b>&nbsp;&nbsp;How Will I Know If My Premium Is Changing?</b></p> <p class=MsoNormal style='text-align:justify'>&nbsp;</p> <p class=MsoNormal style='margin-left:45.0pt;text-align:justify;text-indent: -45.0pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; The company will send you a notice. The notice will include the new premium and when you will start paying it. It also will give you ways you could avoid paying a higher premium. One likely choice will be to keep your insurance policy, but with fewer or lower benefits than you bought. Another choice may be to stop paying premiums and have a &quot;paid-up&quot; policy with fewer or lower benefits than the policy you bought. You may have other choices.</p> <p class=MsoNormal style='text-align:justify'>&nbsp;</p> <p class=MsoNormal style='text-align:justify'><b>*&nbsp;&nbsp;Contingent Nonforfeiture</b></p> <p class=MsoNormal style='text-align:justify'>&nbsp;</p> <p class=MsoNormal style='text-align:justify'>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:</p> <p class=MsoNormal style='text-align:justify'>&nbsp;</p> <p class=MsoNormal style='text-align:justify'>You will keep some long-term care insurance coverage, if:</p> <p class=MsoNormal style='text-align:justify'>&nbsp;</p> <p class=MsoNormal style='margin-left:.25in;text-align:justify;text-indent: -.25in'><span style='font-family:Symbol'>·<span style='font:7.0pt "Times New Roman"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span>Your premium after the increase exceeds your original premium by the percentage shown (or more) in the following table; and</p> <p class=MsoNormal style='text-align:justify'>&nbsp;</p> <p class=MsoNormal style='margin-left:.25in;text-align:justify;text-indent: -.25in'><span style='font-family:Symbol'>·<span style='font:7.0pt "Times New Roman"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span>You lapse (not pay more premiums) within 120 days of the increase.</p> <p class=MsoNormal style='text-align:justify'>&nbsp;</p> <p class=MsoNormal style='text-align:justify'>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.</p> <p class=MsoNormal style='text-align:justify'>&nbsp;</p> <p class=MsoNormal style='text-align:justify'>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.</p> <p class=MsoNormal style='text-align:justify'>&nbsp;</p> <p class=MsoNormal style='text-align:justify'>Should you choose this Contingent Nonforfeiture option, your policy, with this reduced maximum benefit amount, will be considered &quot;paid-up&quot; with no further premiums due.</p> <p class=MsoNormal style='text-align:justify'>&nbsp;</p> <p class=MsoNormal style='text-align:justify'><b>Example:</b></p> <p class=MsoNormal style='text-align:justify'>&nbsp;</p> <p class=MsoNormal style='margin-left:.25in;text-align:justify;text-indent: -.25in'><span style='font-family:Symbol'>·<span style='font:7.0pt "Times New Roman"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span>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.</p> <p class=MsoNormal style='text-align:justify'>&nbsp;</p> <p class=MsoNormal style='margin-left:.25in;text-align:justify;text-indent: -.25in'><span style='font-family:Symbol'>·<span style='font:7.0pt "Times New Roman"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span>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).</p> <p class=MsoNormal style='text-align:justify'>&nbsp;</p> <p class=MsoNormal style='margin-left:.25in;text-align:justify;text-indent: -.25in'><span style='font-family:Symbol'>·<span style='font:7.0pt "Times New Roman"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span>Your &quot;paid-up&quot; policy benefits are $10,000 (provided you have at least $10,000 of benefits remaining under your policy).</p> <p class=MsoNormal style='text-align:justify'>&nbsp;</p> <p class=MsoNormal style='text-align:justify'>&nbsp;</p> <div align=center> <table class=MsoNormalTable border=0 cellspacing=0 cellpadding=0 style='border-collapse:collapse'> <tr style='page-break-inside:avoid'> <td width=625 colspan=2 valign=top style='width:468.95pt;border:solid black 1.0pt; border-bottom:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'><b>Contingent Nonforfeiture</b></p> </td> </tr> <tr style='page-break-inside:avoid'> <td width=625 colspan=2 valign=top style='width:468.95pt;border-top:none; border-left:solid black 1.0pt;border-bottom:none;border-right:solid black 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'><b>Cumulative Premium Increase over Initial Premium</b></p> </td> </tr> <tr style='page-break-inside:avoid'> <td width=625 colspan=2 valign=top style='width:468.95pt;border-top:none; border-left:solid black 1.0pt;border-bottom:none;border-right:solid black 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'><b>That Qualifies for Contingent Nonforfeiture</b></p> </td> </tr> <tr style='page-break-inside:avoid'> <td width=625 colspan=2 valign=top style='width:468.95pt;border-top:none; border-left:solid black 1.0pt;border-bottom:none;border-right:solid black 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'>&nbsp;</p> </td> </tr> <tr style='page-break-inside:avoid'> <td width=625 colspan=2 valign=top style='width:468.95pt;border:solid black 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'>(Percentage increase is cumulative from date of original issue. It does NOT represent a one-time increase.)</p> </td> </tr> <tr> <td width=306 valign=top style='width:229.75pt;border:solid black 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'><b>Issue Age</b></p> </td> <td width=319 valign=top style='width:239.2pt;border-top:none;border-left: none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <h1 align=center style='text-align:center'><b>Percent Increase Over Initial Premium</b></h1> </td> </tr> <tr> <td width=306 valign=top style='width:229.75pt;border:solid black 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'>29 and under</p> </td> <td width=319 valign=top style='width:239.2pt;border-top:none;border-left: none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'>200%</p> </td> </tr> <tr> <td width=306 valign=top style='width:229.75pt;border:solid black 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'>30-34</p> </td> <td width=319 valign=top style='width:239.2pt;border-top:none;border-left: none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'>190%</p> </td> </tr> <tr> <td width=306 valign=top style='width:229.75pt;border:solid black 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'>35-39</p> </td> <td width=319 valign=top style='width:239.2pt;border-top:none;border-left: none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'>170%</p> </td> </tr> <tr> <td width=306 valign=top style='width:229.75pt;border:solid black 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'>40-44</p> </td> <td width=319 valign=top style='width:239.2pt;border-top:none;border-left: none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'>150%</p> </td> </tr> <tr> <td width=306 valign=top style='width:229.75pt;border:solid black 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'>45-49</p> </td> <td width=319 valign=top style='width:239.2pt;border-top:none;border-left: none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'>130%</p> </td> </tr> <tr> <td width=306 valign=top style='width:229.75pt;border:solid black 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'>50-54</p> </td> <td width=319 valign=top style='width:239.2pt;border-top:none;border-left: none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'>110%</p> </td> </tr> <tr> <td width=306 valign=top style='width:229.75pt;border:solid black 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'>55-59</p> </td> <td width=319 valign=top style='width:239.2pt;border-top:none;border-left: none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'>90%</p> </td> </tr> <tr> <td width=306 valign=top style='width:229.75pt;border:solid black 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'>60</p> </td> <td width=319 valign=top style='width:239.2pt;border-top:none;border-left: none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'>70%</p> </td> </tr> <tr> <td width=306 valign=top style='width:229.75pt;border:solid black 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'>61</p> </td> <td width=319 valign=top style='width:239.2pt;border-top:none;border-left: none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'>66%</p> </td> </tr> <tr> <td width=306 valign=top style='width:229.75pt;border:solid black 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'>62</p> </td> <td width=319 valign=top style='width:239.2pt;border-top:none;border-left: none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'>62%</p> </td> </tr> <tr> <td width=306 valign=top style='width:229.75pt;border:solid black 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'>63</p> </td> <td width=319 valign=top style='width:239.2pt;border-top:none;border-left: none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'>58%</p> </td> </tr> <tr> <td width=306 valign=top style='width:229.75pt;border:solid black 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'>64</p> </td> <td width=319 valign=top style='width:239.2pt;border-top:none;border-left: none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'>54%</p> </td> </tr> <tr> <td width=306 valign=top style='width:229.75pt;border:solid black 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'>65</p> </td> <td width=319 valign=top style='width:239.2pt;border-top:none;border-left: none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'>50%</p> </td> </tr> <tr> <td width=306 valign=top style='width:229.75pt;border:solid black 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'>66</p> </td> <td width=319 valign=top style='width:239.2pt;border-top:none;border-left: none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'>48%</p> </td> </tr> <tr> <td width=306 valign=top style='width:229.75pt;border:solid black 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'>67</p> </td> <td width=319 valign=top style='width:239.2pt;border-top:none;border-left: none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'>46%</p> </td> </tr> <tr> <td width=306 valign=top style='width:229.75pt;border:solid black 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'>68</p> </td> <td width=319 valign=top style='width:239.2pt;border-top:none;border-left: none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'>44%</p> </td> </tr> <tr> <td width=306 valign=top style='width:229.75pt;border:solid black 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'>69</p> </td> <td width=319 valign=top style='width:239.2pt;border-top:none;border-left: none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'>42%</p> </td> </tr> <tr> <td width=306 valign=top style='width:229.75pt;border:solid black 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'>70</p> </td> <td width=319 valign=top style='width:239.2pt;border-top:none;border-left: none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'>40%</p> </td> </tr> <tr> <td width=306 valign=top style='width:229.75pt;border:solid black 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'>71</p> </td> <td width=319 valign=top style='width:239.2pt;border-top:none;border-left: none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'>38%</p> </td> </tr> <tr> <td width=306 valign=top style='width:229.75pt;border:solid black 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'>72</p> </td> <td width=319 valign=top style='width:239.2pt;border-top:none;border-left: none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'>36%</p> </td> </tr> <tr> <td width=306 valign=top style='width:229.75pt;border:solid black 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'>73</p> </td> <td width=319 valign=top style='width:239.2pt;border-top:none;border-left: none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'>34%</p> </td> </tr> <tr> <td width=306 valign=top style='width:229.75pt;border:solid black 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'>74</p> </td> <td width=319 valign=top style='width:239.2pt;border-top:none;border-left: none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'>32%</p> </td> </tr> <tr> <td width=306 valign=top style='width:229.75pt;border:solid black 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'>75</p> </td> <td width=319 valign=top style='width:239.2pt;border-top:none;border-left: none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'>30%</p> </td> </tr> <tr> <td width=306 valign=top style='width:229.75pt;border:solid black 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'>76</p> </td> <td width=319 valign=top style='width:239.2pt;border-top:none;border-left: none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'>28%</p> </td> </tr> <tr> <td width=306 valign=top style='width:229.75pt;border:solid black 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'>77</p> </td> <td width=319 valign=top style='width:239.2pt;border-top:none;border-left: none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'>26%</p> </td> </tr> <tr> <td width=306 valign=top style='width:229.75pt;border:solid black 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'>78</p> </td> <td width=319 valign=top style='width:239.2pt;border-top:none;border-left: none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'>24%</p> </td> </tr> <tr> <td width=306 valign=top style='width:229.75pt;border:solid black 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'>79</p> </td> <td width=319 valign=top style='width:239.2pt;border-top:none;border-left: none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'>22%</p> </td> </tr> <tr> <td width=306 valign=top style='width:229.75pt;border:solid black 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'>80</p> </td> <td width=319 valign=top style='width:239.2pt;border-top:none;border-left: none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'>20%</p> </td> </tr> <tr> <td width=306 valign=top style='width:229.75pt;border:solid black 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'>81</p> </td> <td width=319 valign=top style='width:239.2pt;border-top:none;border-left: none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'>19%</p> </td> </tr> <tr> <td width=306 valign=top style='width:229.75pt;border:solid black 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'>82</p> </td> <td width=319 valign=top style='width:239.2pt;border-top:none;border-left: none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'>18%</p> </td> </tr> <tr> <td width=306 valign=top style='width:229.75pt;border:solid black 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'>83</p> </td> <td width=319 valign=top style='width:239.2pt;border-top:none;border-left: none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'>17%</p> </td> </tr> <tr> <td width=306 valign=top style='width:229.75pt;border:solid black 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'>84</p> </td> <td width=319 valign=top style='width:239.2pt;border-top:none;border-left: none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'>16%</p> </td> </tr> <tr> <td width=306 valign=top style='width:229.75pt;border:solid black 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'>85</p> </td> <td width=319 valign=top style='width:239.2pt;border-top:none;border-left: none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'>15%</p> </td> </tr> <tr> <td width=306 valign=top style='width:229.75pt;border:solid black 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'>86</p> </td> <td width=319 valign=top style='width:239.2pt;border-top:none;border-left: none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'>14%</p> </td> </tr> <tr> <td width=306 valign=top style='width:229.75pt;border:solid black 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'>87</p> </td> <td width=319 valign=top style='width:239.2pt;border-top:none;border-left: none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'>13%</p> </td> </tr> <tr> <td width=306 valign=top style='width:229.75pt;border:solid black 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'>88</p> </td> <td width=319 valign=top style='width:239.2pt;border-top:none;border-left: none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'>12%</p> </td> </tr> <tr> <td width=306 valign=top style='width:229.75pt;border:solid black 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'>89</p> </td> <td width=319 valign=top style='width:239.2pt;border-top:none;border-left: none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'>11%</p> </td> </tr> <tr> <td width=306 valign=top style='width:229.75pt;border:solid black 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'>90 and over</p> </td> <td width=319 valign=top style='width:239.2pt;border-top:none;border-left: none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'>10%</p> </td> </tr> </table> </div> <p class=MsoNormal style='text-align:justify'>&nbsp;</p> <p class=MsoNormal style='text-align:justify'>[The following contingent nonforfeiture disclosure need only be included for those limited pay policies to which &#167;&#167;&nbsp;20:06:21:58(4)(d) and 20:06:21:58(4)(f) are applicable.]</p> <p class=MsoNormal style='text-align:justify'>&nbsp;</p> <p class=MsoNormal style='text-align:justify'>In addition to the contingent nonforfeiture benefits described above, the following reduced &quot;paid-up&quot; 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 &quot;paid up&quot; benefit AND the contingent benefit described above are triggered by the same rate increase, you can choose either of the two benefits.</p> <p class=MsoNormal style='text-align:justify'>&nbsp;</p> <p class=MsoNormal style='text-align:justify'>You are eligible for the reduced &quot;paid-up&quot; contingent nonforfeiture benefit if all three conditions shown below are met:</p> <p class=MsoNormal style='text-align:justify'>&nbsp;</p> <p class=MsoNormal style='margin-left:.25in;text-align:justify;text-indent: -.25in'>1.&nbsp;&nbsp;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:</p> <p class=MsoNormal style='text-align:justify'>&nbsp;</p> <table class=MsoNormalTable border=1 cellspacing=0 cellpadding=0 style='margin-left:99.6pt;border-collapse:collapse;border:none'> <tr> <td width=386 colspan=2 valign=top style='width:289.85pt;border:solid black 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'><b>Triggers for a Substantial Premium Increase</b></p> </td> </tr> <tr> <td width=192 valign=top style='width:144.1pt;border:solid black 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'><b>&nbsp;</b></p> <p class=MsoNormal align=center style='text-align:center'><b>Issue Age</b></p> </td> <td width=194 valign=top style='width:145.75pt;border-top:none;border-left: none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'><b>Percent Increase Over</b></p> <p class=MsoNormal align=center style='text-align:center'><b>Initial Premium</b></p> </td> </tr> <tr> <td width=192 valign=top style='width:144.1pt;border:solid black 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'>&nbsp;</p> </td> <td width=194 valign=top style='width:145.75pt;border-top:none;border-left: none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'>&nbsp;</p> </td> </tr> <tr> <td width=192 valign=top style='width:144.1pt;border:solid black 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'>Under 65</p> </td> <td width=194 valign=top style='width:145.75pt;border-top:none;border-left: none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'>50%</p> </td> </tr> <tr> <td width=192 valign=top style='width:144.1pt;border:solid black 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'>65-80</p> </td> <td width=194 valign=top style='width:145.75pt;border-top:none;border-left: none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'>30%</p> </td> </tr> <tr> <td width=192 valign=top style='width:144.1pt;border:solid black 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'>Over 80</p> </td> <td width=194 valign=top style='width:145.75pt;border-top:none;border-left: none;border-bottom:solid black 1.0pt;border-right:solid black 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'>10%</p> </td> </tr> </table> <p class=MsoNormal style='text-align:justify'>&nbsp;</p> <p class=MsoNormal style='margin-left:.25in;text-align:justify;text-indent: -.25in'>2.&nbsp;&nbsp;You stop paying your premiums within 120 days of when the premium increase took effect; AND</p> <p class=MsoNormal style='margin-left:.25in;text-align:justify;text-indent: -.25in'>&nbsp;</p> <p class=MsoNormal style='margin-left:.25in;text-align:justify;text-indent: -.25in'>3.&nbsp;&nbsp;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.</p> <p class=MsoNormal style='margin-left:.25in;text-align:justify;text-indent: -.25in'>&nbsp;</p> <p class=MsoNormal style='text-align:justify'>If you exercise this option your coverage will be converted to reduced &quot;paid-up&quot; status. That means there will be no additional premiums required. Your benefits will change in the following ways:</p> <p class=MsoNormal style='margin-left:.25in;text-align:justify;text-indent: -.25in'>&nbsp;</p> <p class=MsoNormal style='text-align:justify'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; a.&nbsp;&nbsp;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.</p> <p class=MsoNormal style='margin-left:.25in;text-align:justify;text-indent: -.25in'>&nbsp;</p> <p class=MsoNormal style='text-align:justify'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; b.&nbsp;&nbsp;The daily benefit amounts you purchased will also be adjusted by the same ratio.</p> <p class=MsoNormal style='text-align:justify'>&nbsp;</p> <p class=MsoNormal style='text-align:justify'>If you purchased lifetime benefits, only the daily benefit amounts you purchased will be adjusted by the applicable ratio.</p> <p class=MsoNormal style='text-align:justify'>&nbsp;</p> <p class=MsoNormal style='text-align:justify'><b>Example:</b></p> <p class=MsoNormal style='margin-left:79.5pt;text-align:justify;text-indent: -.25in'><span style='font-family:Symbol'>·<span style='font:7.0pt "Times New Roman"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span>You bought the policy at age 65 with an annual premium payable for 10 years.</p> <p class=MsoNormal style='text-align:justify'>&nbsp;</p> <p class=MsoNormal style='margin-left:79.5pt;text-align:justify;text-indent: -.25in'><span style='font-family:Symbol'>·<span style='font:7.0pt "Times New Roman"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span>In the sixth year, you receive a rate increase of 35% and you decide to stop paying premiums.</p> <p class=MsoNormal style='text-align:justify'>&nbsp;</p> <p class=MsoNormal style='margin-left:79.5pt;text-align:justify;text-indent: -.25in'><span style='font-family:Symbol'>·<span style='font:7.0pt "Times New Roman"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span>Because you have already paid 50% of your total premium payments and that is more than the 40% ratio, your &quot;paid-up&quot; 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 &quot;paid-up&quot; policy.</p> <p class=MsoNormal style='text-align:justify'>&nbsp;</p> <span style='font-size:12.0pt;font-family:"Times New Roman",serif'><br clear=all style='page-break-before:always'> </span> <p class=MsoNormal>&nbsp;</p> </div> </body> </html>