California Life Settlement Qualification Form

Transcription

1 PERSONAL INFORMATION California Life Settlement Qualification Form First Insured Name: SS # Current Address: City: State: Zip: Date of Birth: Driver s License Number: State: Expiration: Second Insured Name: SS # Current Address: City: State: Zip: Date of Birth: Driver s License Number: State: Expiration: Daytime Telephone Number: Evening Telephone Number: Marital Status: Male: Female: Dependent Children: Yes ( ) No ( ) If any of the following apply please provide documentation: Divorce, Advanced Directives, Power of Attorney, Civil Suits/Judgments, Tax Liens, Creditor Liens Have you been or are you now a party to bankruptcy? Yes ( ) No ( ) If yes, please attach all discharge papers. IF POLICY OWNER IS DIFFERENT THAN INSURED Policy Owner (if other than insured): Name of Officer or Trustee: SS or Tax ID #: Current Address: City: State: Zip: Date of Birth/Formation: Driver s License Number: State: Expiration: Daytime Telephone Number: Evening Telephone Number: Marital Status: Male: Female: Dependent Children: Yes ( ) No ( ) If any of the following apply please provide documentation: Divorce, Advanced Directives, Power of Attorney, Civil Suits/Judgments, Tax Liens, Creditor Liens Have you been or are you now a party to bankruptcy? Yes ( ) No ( ) If yes, please attach all discharge papers. Please list any additional Owners, Trustees or Beneficiaries including address and telephone information on a separate sheet. TFS-QP1-CA10/1

2 LIFE INSURANCE POLICY INFORMATION Name of Insurance Company: Policy Number: Date policy was issued: Coverage/Face Amount:$ Amount of Premium:$ (monthly/quarterly/semi-annually/annually) Loan Amount:$ Current Surrender Amount: $ List any Policy Riders/Supplemental Benefits (i.e.; Accidental Death, Premium Waiver, etc.): Beneficiaries: Type of Policy: Term ( ) Whole Life ( ) Universal Life ( ) Group (employer) ( ) Other ( ) Policy Premium Financed? - Yes ( ) No ( ) Finance Company What is the Reason for the Financing of this Policy? What is the Reason for the Sale of this Policy? MEDICAL HISTORY Name of Personal Physician(s): Address: City/State/Zip: Telephone #: Facsimile #: Give a description of your current and past medical condition(s) and diagnosis dates: Date of last medical treatment/appointment: Reason for visit: Have you been diagnosed with a life threatening or catastrophic illness? - Yes ( ) No ( ) Please list the names and phone numbers of any additional Physicians and/or Specialists: Name: Telephone #: Name: Telephone #: Name: Telephone #: FRAUD WARNING ANY PERSON WHO KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE OR AN APPLICATION FOR A LIFE SETTLEMENT CONTRACT IS GUILTY OF CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON TFS-QP2-CA10/1

3 LIFE SETTLEMENT QUALIFICATION AND DISCLOSURE STATEMENT 1. There are alternatives to the process of selling your policy which may be preferable. Some alternatives, where applicable, are borrowing against the policy, surrendering the policy, or an accelerated death benefit option. Information on these alternatives should be obtained from the Insurer that issued the policy. 2. Receipt of the proceeds of a Life Settlement may adversely affect the Viator s eligibility for Medicaid, supplemental Social Security Income or other governmental benefits or entitlements. Advice should be obtained from the appropriate government agencies, or from a professional advisor. Entering into a life settlement contract may cause rights or benefits including conversion rights and waiver of premium benefits that may exist under the policy or certificate to be forfeited by the Viator and assistance should be sought from a financial advisor. There are consequences for interruption of public assistance as provided by information provided by the State Department of Health Care Services and the State Department of Social Services under Section of the Welfare and Institutions Code. 3. Proceeds of a Life Settlement may be taxable under federal income tax, or subject to the claims of creditors. Before completing a Life Settlement contract, you are urged to consult with a personal tax advisor. The money you receive for your life insurance policy could be taken away from you by creditors, personal representatives, trustees in bankruptcy and receivers in state or federal court. 4. The Viator has the right to know, upon request, the identity of any person who will receive or has received a commission or other form of compensation from the Life settlement provider with respect to their Life settlement and the amount and terms of such compensation. 5. Trinity Settlements and Insurance Services, LLC, will be compensated. The Life settlement provider company, not the Viator, will compensate Trinity Settlements and Insurance Services, LLC, based on a formula that is a percentage of the face value of the life insurance policy. For example: compensation for a $500,000 policy could be: 8% x $500,000 (face value) = $40, Compensation can include, but is not limited to, bonuses, overrides or other funds in addition to agent commissions. 6. The owner has the right to rescind a Life Settlement contract within thirty (30) days of the date it is executed by all parties and the owner has received all disclosures, or fifteen (15) calendar days after the receipt of the Life Settlement proceeds by the owner, whichever is sooner. If the insured dies within the rescission period, the Life Settlement contract shall be deemed to have been rescinded, subject to repayment of all Life Settlement proceeds and any premiums, loans and loan interest in to the Life Settlement Provider or Life Settlement Purchaser, by the owner or the owner s estate Rescission, if exercised by the owner, is effective only if both notice of rescission is given and the owner repays all proceeds and any premiums, loans and loan interest paid on account of the provide within the rescission period. TFS-QP3-CA10/1

4 LIFE SETTLEMENT QUALIFICATION AND DISCLOSURE STATEMENT (Cont d) 7. Funds will be sent to the Viator within three (3) business days after the Provider has received the insurer acknowledgement that ownership of the policy or interest in the certificate has been transferred and the beneficiary has been designated. NOTE: You may inspect or receive copies of the relevant escrow agreement. 8. All medical, financial or personal information solicited or obtained by a Life settlement provider or a Life settlement broker about an insured, including the insured s identity or the identity of family members, a spouse or significant other may be disclosed as necessary to effect the Viatical settlement between the owner and the Life settlement provider. If you are asked to provide this information, you will be asked to consent to the disclosure. The information may be presented to someone who buys the policy or provides funds for the purchase. You may be asked to renew your permission to share information every two years. 9. The Life Settlement provider may assign or otherwise transfer its interests in the viaticated policy to a third party. 10. The insured may be contacted by the Life Settlement provider, broker or its authorized representative for the purpose of determining the insured s health status. This contact is limited to once every three months following the date the life settlement proceeds are released to the Viator if the insured has a life expectancy of more than one year, and no more than once per month following such date if the insured has a life expectancy of one year or less. 11. Sale of a policy (or change of ownership of a policy) could impact the insured s ability to purchase future insurance on the insured s life because there is a limit to how much coverage insurers will issue on one life. 12. The broker represents the policy owner exclusively and not the insurer, provider or any other person and owes a fiduciary duty to the owner including a duty to act according to the instruction and best interest of the owner. 13. Notice to Applicant. Trinity Settlements and Insurance Services, LLC makes no representation or guaranty that Applicant s policy(s) will be sold. Trinity Settlements and Insurance Services, LLC is not responsible for any failure on the part of a potential Viatical settlement provider to purchase Applicant s policy(ies) on terms offered by a Life settlement provider through Trinity Settlements and Insurance Services, LLC. Trinity Settlements and Insurance Services, LLC is not responsible for the accuracy of any representations made by a Life settlement provider of Applicant s policy(ies). Applicant acknowledges that he/she has determined the relative benefit or any such Life settlement transaction after review of the legal and financial implications of such a settlement with his/her attorney, accountant, or other appropriate advisor. Applicant has voluntarily released his/her medical records requested by Trinity Settlements and Insurance Services, LLC and acknowledges that he/she freely and voluntarily provided the information requested as part of the Qualification Form. TFS-QP4-CA10/1

5 LIFE SETTLEMENT QUALIFICATION AND DISCLOSURE STATEMENT (Cont d) A broker shall provide the owner and the provider with at least the following disclosures not later than the date the life settlement contract is signed by all parties. The disclosures shall be conspicuously displayed in the life settlement contract or in a separate document signed by the owner and provide the following information: a) The name, business address and telephone number of the broker; b) A full, complete and accurate description of all the offers, counter-offers, acceptances and rejections relating to the proposed life settlement contract; c) A written disclosure of any affiliations or contractual arrangements between the broker and any person making an offer in connection with the proposed life settlement contract; d) The name of each broker who receives compensation and the amount of compensation received by said broker, which compensation includes anything of value paid or given to the broker in connection with the life settlement contract; e) All estimates of the life expectancy of the insured which are obtained by the licensee in connection with the life settlement, unless such disclosure would violate any California or federal privacy laws. f) The commissioner may consider any failure to provide the disclosures or rights described in this section as a basis for suspending or revoking a broker s or provider s license pursuant to paragraph (2) of subdivision (b). A provider or broker must provide in writing, in a separate document signed by the owner and the provider/broker, the following disclosures not later than the date the life settlement contract is signed by all parties A. the amount and method of calculating the compensation paid or to be paid to the broker or to any other person acting for the owner in connection with the transaction, wherein the term compensation includes anything of value paid or given. B. The date by which funds will be available to the owner and the transmitter of the funds. C. A buyer s guide or similar consumer advisory package approved by the California Commissioner of Insurance. D. The affiliation, if any, between the provider and the issuer of the policy to be sold E. The name, address and phone number of the provider F. The name, business address and phone number of the independent third party escrow agent, and the fact that the owner may inspect or receive copies of the relevant escrow or trust agreements or documents G. Change of ownership of the policy could limit the insured s ability to purchase future insurance on the insured s life because there is a limit to how much coverage insurers will issue on one life. TFS-QP5-CA10/1

6 My signature below acknowledges my full understanding of the policy and the life settlement transaction considered. My signature below acknowledges my belief that I am of sound mind. My signature below acknowledges that I voluntarily release the required information. Signature of 1 st Insured: Date: Signature of 2nd Insured: Date: Signature of Policy Owner(s)/Viator Date: Signature of Policy Owner(s)/Viator Date: Signature of Witness: Date: TFS-QP6-CA10

7 AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION (HIPAA COMPLIANT) The undersigned insured (hereafter referred to as I, me or my ), authorize the disclosure of my protected health information as defined under the privacy regulations promulgated pursuant to the Health Insurance Portability and Accountability Act of 1996 ( PHI ) as follows: 1. I hereby authorize any physician, medical practitioner, hospice, hospital, clinic, health care provider, or other medical or medically related facility, insurance support organization, pharmacy, governmental agency, insurance company, group policyholder, employer, benefit plan administrator, or any other institution or person (each, an Authorized Discloser ) to provide Trinity Settlements and Insurance Services, LLC and/or its authorized representative, my life insurer (collectively, the Authorized Recipient ) with any and all information as to diagnosis, treatment and prognosis with respect to any physical or mental condition including psychiatric conditions, drug or alcohol abuse, of or related to the insured. 2. This authorization allows for the disclosure, inspection, and copying of any and all records, reports, and/or documents, including any underlying data, regarding the care and treatments or hospitalization, including, but not limited to, all testing materials completed by or administered to the insured, along with any and all medical charts, clinical or doctors notes, memoranda, medical reports, X-ray reports, index cards, history notes, pictures, records and medical bills in your possession and control. This authorization shall apply to any and all of the insured s health and medical records and information, whether or not personally identifiable or protected under any federal or state confidentiality or privacy laws or regulations. 3. I understand that Viatical settlement providers, their medical underwriters, contingency reinsurers and any other entity which requires or is compelled by law to receive such PHI to complete a life settlement contract transaction or in order to sell a life settlement contract (each Authorized Recipient ) will use information released or obtained pursuant to this authorization for the purpose of pursuing and/or completing the sale of life insurance policy(ies) of which I am the owner or which I am the insured, and I hereby expressly authorize such use and disclosure of my PHI made under this authorization. I understand that my PHI may be secured by a third-party provider and may be electronically transmitted to the Authorized Recipient, including transmission via web posting to a secure web site. I agree that a photocopy or facsimile of this authorization shall be valid as the original. Signature of 1 st Insured: Date: Signature of 2nd Insured: Date: Signature of Policy Owner(s)/Viator Date: Signature of Policy Owner(s)/Viator Date: Signature of Witness: Date: TFS-QP7-CA10

8 AUTHORIZATION CONTINUED 4. I agree that this authorization shall remain valid for the life of the undersigned (or the last to survive of the undersigned if more than one signatory) or until the policy lapses without the possibility of reinstatement, whichever is earlier, absent any provisions of any applicable state statute or regulation to the contrary, in which event it shall remain valid for the maximum period permitted there under. 5. Right to Revoke Authorization: I acknowledge and understand that I may revoke this authorization any time with respect to any Authorized Discloser by notifying such Authorized Discloser in writing of my revocation of this authorization and delivering my revocation by mail or personal delivery at such address designated to me by such Authorized Discloser; 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 written notice of my revocation. 6. Inability to Condition Treatment, Payment, Enrollment or Eligibility for Benefits on Provision of Authorization: I understand that this authorization is voluntary and I am not required to sign. No Authorized Discloser or other covered entity may condition my treatment, payment, enrollment or eligibility for benefits on whether I sign this authorization. I understand that this authorization is not a consent or an authorization requested by a health care provider, health care clearinghouse 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, there is the potential for my PHI that is disclosed by any Authorized Discloser to an Authorized Recipient to be subject to re-disclosure by the Authorized Recipient and my PHI that is disclosed to such Authorized Recipient 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. I further certify that this authorization is written in plain language and that I have retained a copy of this signed authorization for future reference. Any person who knowingly presents false information in an application for insurance or an application for a life settlement contract may be guilty of a crime and may be subject to fines and confinement in prison. Signature of 1 st Insured: Date: Signature of 2nd Insured: Date: Signature of Policy Owner(s)/Viator Date: Signature of Policy Owner(s)/Viator Date: Signature of Witness: Date: TFS-QP8-CA10

9 AUTHORIZATION FOR DISCLOSURE OF INSURANCE POLICY INFORMATION The undersigned insured (hereafter referred to as I, me or my ), authorize the disclosure of my protected health information 1. Release of Policy Information. (For Financial Purposes). I understand that the information authorized for release may also include life insurance policy information, including but not limited to, applications, forms, Verification of Coverage, Illustrations, riders and amendments concerning any life insurance policy under which my life is insured. I hereby authorize my life insurance company, insurance support organizations, group policy holder, employer, benefit plan administrator or other institution or person to furnish Trinity Financial Services, LLC with any information herein described above. 2. This authorization allows for the disclosure, inspection, and copying of any and all records, reports, and/or documents, including any underlying data related to the issuance of the policy. This Authorization shall apply to any and all of the insured s information, whether or not personally identifiable or protected under any federal or state confidentiality or privacy laws or regulations. 3. I agree that this authorization shall remain valid for the life of the undersigned (or the last to survive of the undersigned if more than one signatory) or until the policy lapses without the possibility of reinstatement, whichever is earlier, absent any provisions of any applicable state statute or regulation to the contrary, in which event it shall remain valid for the maximum period permitted there under. 4. Right to Revoke Authorization: I acknowledge and understand that I may revoke this authorization any time with respect to any Authorized Discloser by notifying such Authorized Discloser in writing of my revocation of this authorization and delivering my revocation by mail or personal delivery at such address designated to me by such Authorized Discloser; 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 written notice of my revocation. TFS-QP9-CA10

10 5. Inability to Condition Treatment, Payment, Enrollment or Eligibility for Benefits on Provision of Authorization: I understand that this authorization is voluntary and I am not required to sign. No Authorized Discloser or other covered entity may condition my treatment, payment, enrollment or eligibility for benefits on whether I sign this authorization. I certify that I am executing and delivering this authorization freely and unilaterally as of the date written below. I further certify that this authorization is written in plain language and that I have retained a copy of this signed authorization for future reference. Any person who knowingly presents false information in an application for insurance or an application for a life settlement contract may be guilty of a crime and may be subject to fines and confinement in prison. Signature of 1 st Insured: Date: Signature of 2nd Insured: Date: Signature of Policy Owner(s)/Viator Date: Signature of Policy Owner(s)/Viator Date: Signature of Witness: Date: TFS-QP10-CA10