Long Term Care Insurance Policy Schedule of Benefits

COMMENT: The following is a typical Schedule of Benefits page for a long term care insurance policy.

Sample Life Insurance Company
P.O. Box 123456
Anytown, NY 22212-7890
Toll Free Number: 1-800-987-6543

SCHEDULE OF BENEFITS

INSURED
Robert W. Brown

CURRENT COVERAGE: EFFECTIVE DATE - June 11, 2007
(REPLACES ANY PREVIOUS SCHEDULE OF BENEFITS)


Original Coverage Effective Date
Original Issue Age
Policy Number
Plan Number
Elimination Period
TOTAL LIFETIME BENEFIT (does not reflect claims paid or payable)
June 11, 2007
46
06758-493210
6758
100 days
$500,000

COMMENT: The Elimination Period is the total number of days after the Original Coverage Effective Date during which the Insured must be Chronically Ill and receiving Primary Services before certain Benefits become payable. No Elimination Period is required in order to receive Benefits for Respite Care, Needs Assessment or Informal Caregiver Training. The Insured only has to satisfy the Elimination Period once during the lifetime of the Policy.
COVERED SERVICES BENEFIT AMOUNTS

PRIMARY SERVICES
Nursing Home
Assisted Living Facility
Respite Care – 21 days/Policy Year



-In a Nursing Home or Facility-At Home or in an Assisted Living Facility

Home Care and Community Care

ADDITIONAL SERVICES
Needs Assessment
Informal Caregiver Training

MAX DAILY BENEFIT AMOUNT
$120.00
$120.00


$100
$100


$100


MAXIMUM BENEFIT AMOUNT
Free or $250/lifetime
$500/lifetime

Health Rating: Preferred

Discounts: Spousal Discount

Spousal Discount applies as long as associated policies remain in force.

COMMENT: The Spousal Discount applies when, and only when each spouse has an individual long term care insurance policy with Sample Life.

PREMIUM SCHEDULE

Gross Annual Premium (includes Riders and Health Rating; does not include Discounts, if any)

COVERAGE

Base Coverage
5% Automatic compound Inflation Protection Rider
Contingent Benefits Upon Lapse Rider
Paid-Up Premiums Rider
Total Annual Premium with Discounts applied
Monthly Premium Amount*

$1,277.86

ANNUAL PREMIUM*
(includes Health Rating and Discounts)

$ 365.04
$ 429.72
$ 0.00
$ 341.76
$1,136.52
$ 94.71

* If You pay premiums more frequently than annually, an additional charge has been included.