Robert Stark Life Settlement Data Request Form Connecticut

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1 Robert Stark CT Life Settlement Data Request Form Life Settlement Data Request Form Connecticut

2 Life Settlement Data Request Form LIFE INSURANCE POLICY INFORMATION Name of Insurance Company Face Amount Policy Number Account Value Total Policy Loan Type of Policy (check all that apply): Annual Premium Policy (mo/dd/yr) TERM UL Premium Mode SUL VUL Cash Surrender Value SVUL INDEX Last Premium Paid (mo/dd/yr) Name of Beneficiary(ies) WL SWL Next Premium Due (mo/dd/yr) Reason for Policy Sale SELLER INFORMATION (INDIVIDUAL) Name of Seller Permanent Residence Marriage Status: Single of Birth (mo/dd/yr) Gender: Married Divorced Male Legally Separated Female Widowed SELLER INFORMATION (TRUST) Name of Trust Tax ID Number of Trust of Trust (mo/dd/yr) Name of Trustee of Birth (mo/dd/yr) Law Governing Trust Gender: Male Female SELLER INFORMATION (CORPORATE) Name of Corporation Tax ID Number Name of Authorized Officer & Title Corporate of Incorporation (mo/dd/yr) of Birth (mo/dd/yr) of Domicile Gender: Male Female *Any person who knowingly presents false information in an application for insurance or life settlement contract is guilty of a crime and may be subject to fines and confinement in prison. CT-RSDRF 1

3 Life Settlement Data Request Form INSURED INFORMATION Name of Insured of Birth (mo/dd/yr) Permanent Residence Length of Residence: Citizenship: Height Weight Gender: Male US Female Other Tobacco Use: Smoker Non-Smoker Description of Medical History & Condition(s) INSURED PRIMARY PHYSICIAN Name of Primary Physician & Specialty Phone Number & Reason Last Seen INSURED SPECIALIST OR OTHER PHYSICIAN Name of Specialist Physician & Specialty Phone Number & Reason Last Seen HOSPITALIZATION INFORMATION Name of Hospital & Reason for Hospitalization CT-RSDRF 2

4 Life Settlement Data Request Form SECOND INSURED INFORMATION (IF APPLICABLE) Name of Second Insured Permanent Residence Length of Residence: Height: of Birth (mo/dd/yr) Male Citizenship: Weight: Gender: US Tobacco Use: Female Other Smoker Non-Smoker Description of Medical History & Condition(s) SECOND INSURED PRIMARY PHYSICIAN Second Insured Primary Physician & Specialty Phone Number & Reason Last Seen SECOND INSURED SPECIALIST OR OTHER PHYSICIAN Name of Specialist Physician & Specialty Phone Number & Reason Last Seen HOSPITALIZATION INFORMATION Name of Hospital & Reason for Hospitalization CT-RSDRF 3

5 Life Settlement Data Request Form AUTHORIZATION Please include this Authorization to release records and policy information with this application. I hereby authorize each physician, doctor, physician practice group, nurse, pharmacy, hospital, clinic and/or any of its affiliates, directors, officers, employees, agents, independent contractors, service providers or other authorized representatives of the below listed companies any and all information and/or records as to diagnosis, treatment and/or prognosis (including any and all dates thereof) concerning my past, present or future physical or mental history or condition. I also specifically authorize each Authorized Discloser to release to the below listed companies the results of any HIV or AIDS test as well as any other information relating to sexually transmitted diseases, drug or alcohol abuse and psychiatric evaluations and/or information. I understand that all medical information disclosed hereunder will be treated as confidential and will only be used by in connection with obtaining a decision to purchase and/or sell one or more life insurance policies under which my life is insured. I further understand that I am not required to sign this Authorization in order to obtain health care benefits (treatment, payment or enrollment)i hereby authorize my insurance company to furnish with any information, illustrations and/or forms in connection with any life insurance policy under which my life is insured (including any conversions thereof or replacements therefore). I acknowledge and understand that I may revoke this Authorization at any time with respect to any Authorized Discloser by notifying such Authorized Discloser of my revocation of this Authorization in writing and delivering my revocation by mail or personal delivery at such address designated by such Authorized Discloser; provided, that, any revocation of this Authorization shall not apply to the extent that (i) the Authorized Discloser has taken action in reliance upon this Authorization prior to receiving notice of my revocation or (ii), if this Authorization was obtained as a condition of obtaining insurance coverage, other law provides an insurer with the right to contest a claim under an insurance policy. I understand that if the viatical settlement provider transfers ownership or changes the beneficiary of the insurance policy, the viatical settlement provider shall communicate the change of ownership or beneficiary to the insured no later than twenty days after the change. I understand that this Authorization is not a consent or an authorization requested by a health care provider, health care clearing house or health plan covered by the privacy regulations promulgated pursuant to the Health Insurance Portability and Accountability Act of 1996 (the HIPAA Privacy Regulations ). I further understand that, as a result of this Authorization, any of my medical information disclosed by any Authorized Discloser to may be redisclosed and may no longer be protected by the HIPAA Privacy Regulations. I certify that I am executing and delivering this Authorization freely and unilaterally as of the date written below and that all information contained in this Authorization is true and correct. I further certify that this Authorization is written in plain language and I fully understand its contents. I will retain a copy of this signed Authorization for future reference. I specifically authorize and request my insurance company and each Authorized Discloser to rely upon a photostatic or facsimile copy or other reproduction of this Authorization. This Authorization shall remain valid until, and shall expire on, the date one year following the date of my death. INSURED SIGNATURES AUTHORIZED DISCLOSURES Name of Insured Signature of Insured of Birth Name of Second Insured Signature of Second Insured of Birth OWNER SIGNATURES AUTHORIZED DISCLOSURES Name of Owner Signature of Owner/Seller OR Tax ID Number of Owner Signature of Financial Advisor CT-RSDRF 4

6 INSURANCE INFORMATION REQUEST FORM To: Life Insurance Co. Re: Insured Policy No. I hereby authorize and request that any insurance company or any other institution or person having custody or control of any insurance records or similar information relating to any individuallife insurance policy or a certificate of insurance under a group policy that I own to release anyand all such insurance information concerning me to as promptly as possible. This letter represents my continuing authorization to you, unless consent is subsequently withdrawn. Please retain this letter in my files as a record of this authorization and release. Any correspondence with may be sent to the following address: 88 Froehlich Farm Blvd, Suite 206 Woodbury, NY Toll Free: Facsimile: A signed photocopy of this release shall be equally as binding as a copy with my original signature. Sincerely, Signature of Policy Owner or Signature of Trustee Name of Policy Owner or Name of Trust of Owner or Tax ID Number of Owner CT-RSIIRF 5

7 EXCLUSIVE AGENCY AGREEMENT TO WHOM IT MAY CONCERN: I,, appoint and any of it s successors and affiliate entities as the exclusive Agent of Record for the Life Insurance Policies listed below for the purpose of negotiating the sale of said Policies on my behalf. Further, I agree not to appoint any other individual or entity as Agent of Record without revoking this Agent of Record agreement by written notice to. All other Agent of Record agreements signed by me prior to the date of this Agent of Record agreement are null and void and all other 3rd parties should cease and desist their marketing of said policies and should not be comunicated with further by any potential funding sources. Policy No. Policy No. Policy No. Policy No. A signed photocopy of this release shall be equally as binding as a copy with my original signature. Sincerely, Signature of Policy Owner or Signature of Trustee Name of Policy Owner or Name of Trust of Owner or Tax ID Number of Owner CT-RSEAA 6

8 APS REQUEST FORM Agent s Name $ Client s Name Face Amount Phone of Birth (mo/dd/yr) Does the client have any current medical conditions? If yes, please describe. Is client taking any medications? If yes, please provide name of drugs and dosages. Has client been hospitalized or had any surgery in the past 10 years? If yes, please describe. Has client seen a physician for any medical condition other than routine physicals? If yes, please describe. Attached find the names, addresses, phone numbers and fax numbers for the doctors that have rendered (or are rendering) medical care and for any facilities that have performed special testing. Also enclosed is any additional information regarding the client s health. (If more space is needed, please attach an additional page.) Doctor s name A ddress Ci ty Phone Fax Doctor s name Phone Fax CT-RSAPSREQ 7

9 HIPAA AUTHORIZATION FORM THIS AUTHORIZATION COMPLIES WITH THE HIPAA PRIVACY RULE Name of Primary Proposed Insured/Patient of Birth Name of Secondary Proposed Insured/Patient of Birth I authorize any health plan, physician, health care professional, hospital, clinic, laboratory, pharmacy, pharmacy benefit manager, medical facility, insurance company, insurance support organization (such as MIB, Inc.) or other health care provider that has provided payment, treatment or services to me or on my behalf or to or on the behalf of my unemancipated minor children ( My Providers ) to disclose the entire medical record and any other protected health information concerning me or my unemancipated minor children to the company(ies) referenced on this authorization ( the Company(ies ) and its agents, employees, and representatives. This includes information on the diagnosis or treatment of Human Immunodeficiency Virus (HIV) infection and sexually transmitted diseases. I authorize the company(ies) to release any such information to reinsuring companies, or other persons or organizations performing business or legal service for the company(ies). This also includes information on the diagnosis and treatment of mental illness and the use of alcohol, drugs, and tobacco, including psychotherapy notes. Companies to include but not be restricted to: American General Associated Life Bankers Life of NY Companion Life Coventry Hartford Indianapolis Life Melville Capital Jackson National Jefferson Pilot John Hancock Manulife (John Hancock USA) Maple Life Financial Mass Mutual US Financial US Life and any or all of their reinsuring companies. Prudential AXA Capitas Midland National Mutual of Omaha North American Company Transamerica Insurance & Investment Group Travelers Insurance Company Travelers Life & Annuity Company By my signature below, I acknowledge that any agreement I have made to restrict my protected health information or that of my unemancipated minor children do not apply to this authorization and I instruct My Providers to release and disclose the entire medical record without restriction. This protected health information is to be disclosed under this Authorization at my request, as permitted by (c ) (1) (iv) of the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule. This authorization shall remain valid, and expire, on the first anniversary of my death, unless revoked in writing at any time by mail or personal delivery, provided that any revocation of this authorization shall not apply to the extent that the Authorized Discloser has taken action in reliance upon this authorization prior to receiving notice of my revocation or if this authorization was obtained. I understand that any information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal regulations governing privacy and confidentiality of health information (such as the HIPAA Privacy Rule). However, the Company(ies) will protect the privacy of health information in accordance with other applicable state and/or federal privacy laws and its own privacy policy. I understand that My Providers may not refuse to provide treatment or payment for health care services because I refuse to sign this authorization. I further understand that if I refuse to sign this authorization to release my complete medical record or that of my unemancipated minor children, the Company(ies) may not be able to process my application, or if coverage has been issued may not be able to make any benefit payments. The purpose of this release is to obtain insurance and/or information relating to the exercise of my rights under any polices issued. I acknowledge that I have received a copy of this authorization. Signature of Primary Proposed Insured/Patient or Personal Representative Signature of Secondary Proposed Insured/Patient or Personal Representative Description of Personal Representative s Authority or Relationship to Patient of Primary Insured/Patient of Secondary Insured/Patient CT-RSHIPAA 8

10 Connecticut Fraud Warning Disclosure CT-RSFWD 9

11 Connecticut Fraud Warning Disclosure CT-RSFWD 10

12 Connecticut Fraud Warning Disclosure CT-RSFWD 11

13 Defining the Terms A life settlement is the sale of a life insurance policy to another person or company in return for a cash payment of less than the full amount of the death benefit. A life settlement provider is the person or company that becomes the new policy owner in return for a payment made to the seller. The life settlement provider becomes the policy owner, must pay any premiums that are due, and eventually collects the full amount of the death benefit from the insurance company. A life settlement broker is the person or company who represents the seller of the policy and can comparison shop for life settlement offers. The buyer pays the broker a commission if the sale is completed. Additional Questions to Consider Do I still need life insurance protection? Will I qualify for a new life insurance policy in the future? If I sell my policy, how will they decide how much cash I get? If I sell my policy, will there be any costs I have to pay? If I sell my policy, will the money be put into an escrow account? If so, who will the escrow agent be? Does state law require the agent to be licensed? Is my policy an employer or other group policy? If so, do I need their permission to sell it? If I sell my policy, who will be the legal owner? Is the viatical settlement provider I plan to sell to allowed to do business in my state? After I sell my policy, can the buyer resell it? Consumer Alert If you re asked to invest in or buy a life settlement, contact your state insurance department to learn more about the issues and risks. If you don t have a life-threatening illness and you re interested in selling your life insurance policy, contact your state insurance department for more information. If you ve been contacted by someone who wants you to buy a policy and then sell it immediately, contact your state insurance department. This activity may be considered fraudulent and the parties may be prosecuted by the appropriate authorities. Check with Your Your state insurance department may regulate the purchase of life settlements. Contact them for a copy of those regulations. This publication was issued in joint cooperation with the: National Association of Insurance Commissioners 2301 McGee Street, Suite 800 Kansas, Mo (816) Selling Your Life Insurance Policy: Understanding Life Settlements

14 Understanding Consider All Your Options Consumer Tips Life Settlements Find out if you have any cash value in your Understand how the process works and A life settlement is the sale of a life insurance policy to a third party. The owner of a life insurance policy sells it for a cash payment that is less than the full amount of the death benefit. The buyer becomes the new owner and/or beneficiary of the life insurance policy, pays all future premiums and collects the full amount of the death benefit when the insured dies. People decide to sell their life insurance policies for many reasons. When an individual with a terminal or chronic illness sells his or her life insurance policy, that is known as a viatical settlement. When an individual who does not have a terminal or chronic illness sells a policy for other reasons, including changed needs of dependents, wanting to reduce premiums, and cash for meeting expenses, that is known as a life settlement. A life settlement may or may not be the right choice for you. Your state insurance department, along with the National Association of Insurance Commissioners, is concerned that many consumers may not fully understand life settlements. Please continue reading before making any decisions. Get All of the Facts Before you enter into any life settlement transaction, you should: Contact your life insurer to learn about all of your possible options under your policy. Contact a life settlement broker or life settlement provider for information about life settlements. Consult with your own financial advisor who knows your personal financial needs. Be sure to ask about tax and other financial consequences if you sell your policy. Contact your state insurance department for information about current laws that may protect you. life insurance policy. You may be able to use some of the cash value to meet your immediate needs and keep your policy in force for your beneficiaries without having to sell it to a third party. You may also be able to use the cash value as security for a loan from a financial institution. Review other sources of cash that may meet your financial needs at a lower cost than a life settlement. Other Considerations Contact a professional tax advisor. Find out the tax implications. Proceeds are only tax-free under certain circumstances. Know that your creditors could claim the proceeds. Find out if you ll lose any public assistance benefits such as food stamps or Medicaid if you get a cash settlement. Know that you must provide certain medical and personal information to third parties who will be paid the proceeds from your policy upon your death. These third parties may sell your policy and pass along your medical and personal information to other individuals. when the different phases will happen. Decide whether to sell your policy directly to a life settlement provider or go through a life settlement broker who will do the comparison shopping for you. If you don t use a life settlement broker, comparison shop on your own. You don t have to accept any life settlement offer. Check all application forms for accuracy, especially information about your medical history. You must be truthful in your answers to application questions. Make sure the life settlement provider agrees to put your settlement proceeds in escrow with an independent party or financial institution to make sure your funds are safe during the transfer. Find out if you have the right to change your mind about the life settlement offer after you get the proceeds. In many states, you have the right to change your mind for a certain period of time. If you have that right, you ll have to return the money you were paid and premiums the buyer paid. Understand whether buyers may learn your identity when they buy your policy, and whether they will know certain medical and personal information about you, such as your address and life expectancy.

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