1. 1. This policy or certificate is (an individual policy of insurance) (a group policy or certificate) that was issued in the (indicate jurisdiction in which the policy or certificate was issued).
2. 2. This disclosure statement provides a very brief description of the important features of the policy or certificate. You should compare this disclosure statement to outlines of coverage for other policies or certificates available to you. This is not an insurance contract, but only a summary of coverage. Only the individual or group policy contains governing contractual provisions. This means that the policy sets forth in detail the rights and obligations of both you and the insurance company. Therefore, if you purchase this coverage, or any other coverage, it is important that you READ YOUR POLICY (OR CERTIFICATE) CAREFULLY!
3. 3. TERMS UNDER WHICH THE POLICY OR CERTIFICATE MAY BE RETURNED AND PREMIUM REFUNDED.
4. (a) (Provide a brief description of the right to return - “free look” provision of the policy or certificate.)
5. 4. THIS IS NOT MEDICARE SUPPLEMENT INSURANCE. If you are eligible for Medicare, review the Medicare Supplement Buyer's Guide available from the insurance company.

6. 5. LONG TERM CARE INSURANCE. Policies or certificates of this category are designed to provide coverage for not less than twenty-four (24) consecutive months for each covered person on an expense incurred, indemnity, prepaid or other basis and provides coverage of all levels of care in a nursing home and home care benefits. This policy or certificate provides coverage in the form of a fixed dollar indemnity benefit for covered long term care expenses, subject to policy or certificate (limitations) (waiting periods) and (coinsurance) requirements. (Modify this paragraph if the policy or certificate is not an indemnity policy or certificate.)

   OR

   NURSING HOME INSURANCE ONLY, HOME CARE INSURANCE ONLY, OR NURSING HOME AND HOME CARE INSURANCE. Policies or certificates of this category are designed to provide coverage for not less than twelve (12) consecutive months for each covered person on an expense incurred, indemnity, prepaid or other basis and provides at least custodial care services in a nursing home (and)(or) home care benefits. This policy or certificate provides coverage in the form of a fixed dollar indemnity benefit for covered expenses, subject to policy or certificate (limitations) (waiting periods) and (coinsurance) requirements. (Modify this paragraph if the policy or certificate is not an indemnity policy or certificate. ) THIS POLICY OR CERTIFICATE DOES NOT PROVIDE LONG TERM CARE INSURANCE AS THAT TERM IS DEFINED BY THE NEW YORK STATE DEPARTMENT OF FINANCIAL SERVICES. (If for a nursing home insurance only policy or certificate or a home care insurance only policy or certificate.) (THIS POLICY)(CERTIFICATE)(DOES NOT PROVIDE COVERAGE FOR NURSING HOME.) (THIS POLICY) (CERTIFICATE) (DOES NOT PROVIDE COVERAGE FOR HOME CARE.)

7. 6. BENEFITS PROVIDED BY THIS (POLICY) (CERTIFICATE).
8. (a) (Covered services, related deductible(s), waiting periods, elimination periods and benefit maximums.)
9. (b) (Institutional benefits, by skill level.)
10. (c) (Non-institutional benefits, by skill level.)

11. (d) Statement that policy or certificate covers Alzheimer's Disease and other organic brain disorders.

    (Any qualifying criteria or benefit screens must be explained in this section. If such criteria or screens differ for different benefits, explanation of the criteria or screen should accompany each benefit description. If an attending physician or other specified person must certify a certain level of functional dependency in order to be eligible for benefits, this too must be specified. If activities of daily living (ADL's) are used to measure an insured's need for care, then these qualifying criteria or screens must be explained.)

12. 7. LIMITATIONS AND EXCLUSIONS.

    (Describe:

13. (a) Preexisting conditions;
14. (b) Exclusions/exceptions;

15. (c) Limitations.)

    (This section should provide a brief specific description of any policy or certificate provisions that limit, exclude, restrict, reduce, delay, or in any other manner operate to qualify payment of the benefits described in (6) above.)

    THIS POLICY OR CERTIFICATE MAY NOT COVER ALL THE EXPENSES ASSOCIATED WITH YOUR LONG TERM CARE NEEDS.

16. 8. (As applicable, indicate the following:
17. (a) That the benefit level will not increase over time;
18. (b) A description of any benefit adjustment provisions and whether these are made without regard to health status;
19. (c) Whether the insured will be guaranteed the option to buy additional benefits and the basis upon which benefits will be increased over time if not by a specified amount or percentage;
20. (d) If there is such a guarantee, include whether additional underwriting or health screening will be required, the frequency and amounts of the upgrade options, and any significant restrictions or limitations;)

21. 9. TERMS UNDER WHICH THE POLICY (OR CERTIFICATE) MAY BE CONTINUED IN FORCE OR DISCONTINUED.

    ((a) Describe the policy or certificate renewability provisions;

22. (b) For group coverage, specifically describe continuation/conversion provisions applicable to the certificate and group policy);
23. (c) For individual coverage, specifically describe conversion rights.

24. 10. PREMIUM.

    ((a) State the total annual premium for the policy or certificate;

25. (b) State whether or not the company has a right to change premium, and if such a right exists, describe clearly and concisely each circumstance under which premium may change.)
26. (c) Include a statement that the policy or certificate either does or does not contain provisions providing for a refund or partial refund of premium upon the death of an insured or surrender of the policy or certificate. If the policy or certificate contains such provisions, include a description of them.)
27. (d) (If the premium varies with an applicant's choice among benefit options, indicate the annual premium associated with each benefit option.)
28. 11. ADDITIONAL FEATURES.
29. (a) Nonforfeiture. Describe nonforfeiture benefits or state policy or certificate does not contain such benefits.
30. (b) Describe other important features.
31. (c) The expected benefit ratio for this policy or certificate is percent. This ratio is the portion of future premiums that the company expects to return as benefits, when averaged over all people with this policy or certificate.

In order to comply with section 52.54 of this Part, policies of individual insurance and certificates and policies of group insurance meeting the definition of section 52.12 or 52.13 of this Part shall use the following statement only, except that appropriate policy identification may be included.

(COMPANY NAME) (LONG TERM CARE INSURANCE) OR (NURSING HOME AND

(HOME CARE INSURANCE) OR (NURSING HOME INSURANCE ONLY) OR (HOME CARE INSURANCE ONLY)

REQUIRED DISCLOSURE STATEMENT

(Policy Number or Group Master Policy and Certificate Number)