The disclosure required by Regulation .03J of this chapter shall read as follows: Long-Term Care Insurance Potential Rate Increase Disclosure Form [Premium Rate] [Premium Rate Schedules]: [Premium rate] [Premium rate schedules] that [is] [are] applicable to you and that will be in effect until a request is made and [filed] [approved] for an increase [is] [are] [on the application] [$ ]) The [premium] [premium rate schedule] for this policy [will be shown on the schedule page of] [will be attached to] your policy. Rate Schedule Adjustments: Potential Rate Revisions: Issue Age Percent Increase Over Initial Premium 55—59 90% 60 70% 61 66% 62 62% 63 58% 64 54% 65 50% 66 48% 67 46% 68 44% 69 42% 70 40% 71 38% 72 36% 73 34% 74 32% 75 30% 76 28% 77 26% 78 24% 79 22% 80 20% 81 19% 82 18% 83 17% 84 16% 85 15% 86 14% 87 13% 88 12% 89 11% 90 and over 10% {The following contingent nonforfeiture disclosure need only be included for those limited pay policies to which COMAR 31.14.01.13E(6) and (9) are applicable.} In addition to the contingent nonforfeiture benefits described above, the following reduced “paid-up” contingent nonforfeiture benefit is an option in all policies that have a fixed or limited premium payment period, even if you selected a nonforfeiture benefit when you bought your policy. If both the reduced “paid up” benefit AND the contingent benefit described above are triggered by the same rate increase, you can choose either of the two benefits. You are eligible for the reduced “paid up” contingent nonforfeiture benefit when all three conditions shown below are met: The premium you are required to pay after the increase exceeds your original premium by the same percentage or more shown in the chart below; You stop paying your premiums within 120 days of when the premium increase took effect; AND The ratio of the number of months you already paid premiums is 40% or more than the number of months you originally agreed to pay. The total lifetime amount of benefits your reduced paid up policy will provide can be determined by multiplying 90% of the lifetime benefit amount at the time the policy becomes paid up by the ratio of the number of months you already paid premiums to the number of months you agreed to pay them. The daily benefit amounts you purchased will also be adjusted by the same ratio. If you purchased lifetime benefits, only the daily benefit amounts you purchased will be adjusted by the applicable ratio.