Robert Stark Utah Life Settlement Application Life Settlement Application Utah
LIFE SETTLEMENT APPLICATION 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 UT-RSAPP Female 1
LIFE SETTLEMENT APPLICATION 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 UT-RSAPP 2
LIFE SETTLEMENT APPLICATION 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 UT-RSAPP 3
LIFE SETTLEMENT APPLICATION 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 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 UT-RSAPP 4
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 individual life insurance policy or a certificate of insurance under a group policy that I own to release any and 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 11797 Toll Free: 800.710.7806 Facsimile: 212.600.9002 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 UT-RSIIRF 5
EXCLUSIVE AGENCY AGREEMENT TO WHOM IT MAY CONCERN: I,, appoint and any of his 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 UT-RSEAA 6
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 UT-RSAPSREQ 7
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 ("My Providers") to disclose the entire medical record and any other protected health information concerning me 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 does 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 164.508 (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, 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 insuranceand/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 UT-RSHIPAA 8
Utah Notice of Disclosure NOTICE OF DISCLOSURE UTAH Fraud Warning: Any person who knowingly presents false information in an application for insurance or a life settlement contract is guilty of a crime & may be subject to fines & confinement in prison. 1. The life settlement producer represents only you and shall act according to your instructions and in your best interest notwithstanding the manner in which life settlement producer is compensated. 2. Some or all of the proceeds of your life settlement may be taxable under federal and state income tax. The life settlement producer is not a tax advisor and recommends that you consult your own professional tax advisor regarding this transaction. 3. The sale of your insurance policy may affect your right to receive Medicaid or other government benefits or entitlements. Advice on such effects should be obtained from the appropriate government agencies. 4. Life settlement proceeds could be subject to the claims of creditors. 5. There may be possible alternatives to selling your life insurance. This may include the option of an accelerated death benefit or policy loans offered by your life insurance company. You are advised to consult a financial advisor, certified public accountant and/or an attorney regarding these potential alternatives. 6. Once you have received your proceeds from the sale of your life insurance policy, you will have fifteen (15) calendar days from receipt of the life settlement proceeds in which to rescind the transaction as provided by Utah Law. If the insured dies during the rescission period, then the settlement is deemed to have been rescinded, subject to repayment of all settlement proceeds and any premiums, loans and loan interest to the life settlement provider or purchaser. 7. Funds will be sent to you within three (3) business days after the life settlement provider has received the insurer or group administrator s written acknowledgment that ownership of the policy or interest in the certificate has been transferred and the beneficiary has been designated. The life settlement producer has no access to or control over life settlement provider funds that are set aside in escrow or trust. 8. Entering into a life settlement contract may 1) cause other rights or benefits, including conversion rights and waiver of premium benefits, which may exist under the policy or a certificate of a group life insurance policy to be forfeited; and 2) reduce the insured s ability to obtain additional life insurance coverage in the future. Assistance should be sought from a financial advisor. 9. Total compensation payable to all life settlement producers shall collectively not exceed a maximum of 12% of the Net Death Benefit (NDB) of your policy. Proceeds of your settlement are represented by the Net Purchase Price (NPP) as follows: NPP = Gross Purchase Price (GPP) as paid by the life settlement provider reduced by the total compensation as described above. 10. All medical, financial or personal information solicited or obtained by a life settlement provider or producer about the 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 life settlement between you 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 (2) years. In addition, information regarding the policy owner s and insured s identity and insured s medical condition will 1) be shared with the insurer that issued the life insurance policy; and 2) shall be available to each subsequent owner of the life insurance policy. 11. The insured may be contacted for the purpose of determining the insured s health status and to confirm the insured s residential or business address and telephone number. This contact shall be limited to once every three (3) months if the insured has a life expectancy of more than one (1) year, and no more than once per month if the insured has a life expectancy of one (1) year or less. All such contacts shall only be made by a life settlement provider licensed in the state in which the owner resided at the time of the life settlement, or by the authorized representative of a duly licensed life settlement provider UT-RSDISC 9
Utah Notice of Disclosure 12. I/we confirm and acknowledge that the life settlement producer has provided me/us with a brochure developed and/or approved by the National Association of Insurance Commissioners (NAIC) describing the process of life settlements. I/We acknowledge that I/we have read and understand the disclosures above (1-12). Signature of Primary Insured Printed Name Signature of Secondary Insured (if applicable) Printed Name Signature of Policy Owner #1 (if not Insured) Printed Name Signature of Policy Owner #2 (if not Insured) Printed Name Signature of Authorized Representative of Life Settlement Producer Printed Name UT-RSDISC 10
Questions to Ask Do I still need life insurance protection? If I sell my policy, how do they decide how much cash I get? Always Check with Your Contact your state insurance or securities departments to learn about the issues and risks of life settlements if: 2004 National Association of Insurance Commissioners Is this an employer or other group policy? If so, do I need permission to sell it? If I sell my policy, who will be the legal owner? Do I need the advice of a tax or estate planning advisor before I decide to sell my policy? Who will have specific information about me, my family or my health status? After I sell my policy, can it be resold by the buyer? Your state insurance department may have a list of life settlement providers and producers that are licensed to do business in the state. Contact them to make sure yours are on the list. you re considering selling your life insurance policy; you re asked to sell your life insurance policy and your health hasn t changed since you bought the policy; you re asked to buy a new life insurance policy and immediately sell it for cash. Buying a Life Insurance Policy? If you re interested in buying a life insurance policy as an investment, contact your state securities department before you make a decision. Selling Your Life Insurance Policy Understanding Life Settlements Tel: 555 555 5555
2004 National Association of Insurance Commissioners What is a Life Settlement? A life settlement is the sale of a life insurance policy to a third party. The owner of the life insurance policy sells the policy for an immediate cash benefit. The buyer (the life settlement provider) becomes the new owner of the life insurance policy, pays future premiums, and collects the death benefit when the insured dies. At one time, most life settlements were from people with a life-threatening illness. Now, individuals who are not facing a health crisis may sell their life insurance policies to get cash. Your state insurance department and the National Association of Insurance Commissioners want you to have the facts before you sell your life insurance policy. This brochure provides some of that information, but it is only a starting point. Consult your own professional financial advisor, attorney, or accountant to help you decide if this is the most suitable arrangement for you. Consider Your Options If you re selling your policy to get cash to pay expenses, check all of your options. You may find a way to get more cash from your life insurance policy. 1. Ask your insurance agent or company if you have any cash value in your 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. You may also be able to use the cash value as security for a loan from a financial institution. 2. Find out if your life insurance policy has an accelerated death benefit. An accelerated death benefit typically pays some of the policy s death benefit before the insured dies. It may be a way for you to get cash from a policy without selling it to a third party. Consumer tips Comparison shop. Get quotes from several companies to make sure you have a competitive offer. Find out the tax implications. Not all proceeds received from the sale of your life insurance policy are tax free. It s important to know that any of your creditors could claim your cash settlement. Find out if you will lose any public assistance benefits such as food stamps or Medicaid if you get a cash settlement. The buyer of your policy can periodically ask you about your health status. The buyer is required to give you a privacy notice outlining who will get this personal information. Be sure to read it. Check all application forms for accuracy, especially your medical history. All questions must be answered truthfully and completely. Make sure the life settlement provider agrees to put your settlement proceeds into an independent escrow account to protect your funds during the transfer. Find out if you have the right to change your mind about the settlement AFTER you get the money. If so, how many days do you have to reconsider and return the money?