Delta Financial - Lost Earnings

Date:

Your Name:

Your Birthdate:

Spouse's Name:

Spouse's Birthdate:

City:

State:

#1. Where do you think you might be living, ten to fifteen years from now?

City:

State:

In another area of the country:

City:

State:

#2. When assistance with activities of daily living* is required, where would you prefer to receive care? *Activities include dressing, bathing, moving about the residence, eating, toileting, and continence.
(Please rate by numbers, with #1 meaning most desirable and #5 least desirable):

At Home

With children

Continuing Care Community ¹1-Continuing care communities generally require good health for admittance. They provide communal meals and care assistance if required later.Some out of pocket care costs may be covered by LTC insurance.

Assisted Living Facility
2-Assisted living facilities generally provide apartment style living, communal meals, and assistance with activities of daily living. Assisted living costs can be covered by most LTC insurance.

Nursing Home

Other

#3 If live at home and need help, who would provide it?
(check one or two below)

Spouse

Children

Family Friend

Housekeeper

Licensed Care Provider

Home Care Agency

If care is provided by family, friends or housekeeper, are you confident that they will have the time, training, and physical strength needed to assist with activities of daily living such as moving about the house, bathing, and hygiene tasks? yes no

#4 How important is it to leave legacy assets to your family, or to favorite charities?

Important

Somewhat important

Not important at all

#5 Do you currently have sufficient liquid assets to pay for long-term care*?

yes

no

*Average annual expenses for nursing home care are $65,000 (higher in many metro areas). One in five people in a nursing home are likely to be there for more that five years. At average costs of $18 per hour for homemaker services, round-the-clock home care could triple those expenses. Based on historic costs, expenses are likely to double in less than fifteen years. Source: Metlife Mature Market Institute, August, 2003.

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