Section 13, Part B.1 - Long Term Care Insurance - Detailed Questions - FOR NEW HOUSEHOLDS ONLY

Section 13, Part B.1 collects detailed information about long term care insurance policies reported in Part A.2.

For definitions Information Booklet »

What is the name of the insurance company for "your (1st, 2nd, 3rd)" long term care policy? [enter text] __________________
* Enter name of insurance company, not the insurance agent.

Briefly describe the policy. [enter text] ______________

Are the policy premiums paid -

  1. Entirely by you or your household?
  2. Partially by you or your household and partially by someone outside your household?
  3. Entirely by an employer or union?
  4. Entirely by another group or persons outside your household?

Are any premiums paid through payroll deductions?

  1. Yes
  2. No

Since the first of the reference month, what was your or your household total expense for this insurance policy? [enter value] ______________

* Enter the actual amount the household paid. Do not include any expenses paid for the household by others

How much was paid this month? [enter value] ______________

* Enter 'C' for a combined expense

  1. C
  2. Not combined expense

What other type of policy is the "long term care insurance" combined with?
* Enter all that apply, separate with commas

  1. Long term care insurance
  2. Life insurance or other policies which provide benefits in case of death or disability
  3. Homeowners' insurance which protects your home, furniture, personal effects or other property against fire, flood, theft, loss or damage
  4. Renters' insurance which protects your home, furniture, personal belongings or other property against fire, flood, theft, loss or damage
  5. Automobile or other vehicle insurance
  6. Other types of non-health insurance
  7. Misc. combined (unable to specify/DK)

Which property (ies) does this policy cover? [enter text] ______________

Do you or any members of your household have any or make payments for any other "long term care insurance" policy?

  1. Yes
  2. No

End of Section 13B Long Term Care Insurance

Go to Section 13 Part B - Life/Disability Insurance - FOR NEW HOUSEHOLDS ONLY »

Go to Section 14 Part A.1 - Hospitalization and Health Insurance »

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Last Modified Date: April 12, 2011