<p> LONG TERM CARE INSURANCE DECLINATION OF COVERAGE</p><p>Date:</p><p>I hereby acknowledge that I have been given the opportunity to apply for Long Term Care Insurance. The long term care insurance plan has been clearly and thoroughly explained to me and I decline to apply for coverage at this time. </p><p>I fully understand that if I later decide to apply for long term care insurance, I will need to satisfy whatever evidence of insurability requirements are needed at that time. It has been explained to me that, in the interim, the premium cost will increase with each passing year.</p><p>A copy of the proposed coverage is attached.</p><p>______Client Name Client Signature</p><p>______Joint Client Name Joint Client Signature</p><p>______Broker Name Broker Signature </p>