Fillable 2013 03 Regulatory Bulletin 2013-03 (Arizona)

Fill Online, Printable, Fillable, Blank 2013 03 Regulatory Bulletin 2013-03 (Arizona) Form

Use Fill to complete blank online ARIZONA pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

2013 03 Regulatory Bulletin 2013-03 (Arizona)

On average this form takes 11 minutes to complete

The 2013 03 Regulatory Bulletin 2013-03 (Arizona) form is 6 pages long and contains:

  • 0 signatures
  • 0 check-boxes
  • 43 other fields

Country of origin: US
File type: PDF

BROWSE ARIZONA FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
FORM P-LSDO: LIFE SETTLEMENT PROVIDER/BROKER DISCLOSURES TO OWNER
PROVIDER/BROKER INFORMATION
Provider/Broker Name:
Business Address:
City State ZIP Code
Phone:
Provider/Broker Representative (if provider/broker is not an individual):
LIFE INSURANCE POLICY OWNER/SELLER INFORMATION
First Name Middle Name Last Name Jr/Sr/III/etc.
Arizona law allows you to sell your life insurance policy to a third party for an amount that is
less than the full death benefit. The buyer becomes the new owner and the beneficiary of the
life insurance policy, pays all future premiums and collects the entire death benefit when you
die. This is called a life settlement contract.
Arizona Revised Statutes (“ARS”) § 20-3204, subsections A and B, require that a life
settlement provider or life settlement broker provide you with the following information in
writing before you apply for or enter into a life settlement contract:
IMPORTANT: READ THIS DISCLOSURE FORM BEFORE SIGNING ANY LIFE
SETTLEMENT CONTRACT
Before you submit an application for a life settlement, you should know:
1. There are possible alternatives to life settlements, including accelerated benefits
options that your life insurer may offer or policy loans.
2. Some or all of the proceeds of a life settlement may be taxable. You should seek
assistance from a professional tax adviser.
3. The proceeds from a life settlement could be subject to the claims of creditors.
4. Receiving proceeds from a life settlement contract may adversely affect your
eligibility for public assistance or other government benefits or entitlements. You
should obtain advice from the appropriate agencies.
5. Entering into a life settlement contract may cause you to forfeit other rights or
benefits including conversion rights and waiver of premium benefits that you may
have under the policy or certificate of a group policy. You should seek assistance
from a professional financial adviser.
6. You can rescind the life settlement contract within fifteen (15) days after the date
that all parties execute the life settlement contract and you have received all required
disclosures (the “rescission period”). To rescind the life settlement contract, you must
notify the provider in writing, and you must repay all proceeds and any premiums,
loans and loan interest paid on account of the provider during the rescission period. If
the insured dies during the rescission period, the life settlement contract shall be
deemed rescinded once you or your estate repay all proceeds and any premiums,
loans and loan interest to the provider.
Form P-LSDO (9/17/2013)
Life Settlement Provider/Broker Disclosures to Owner – Page 2 of 2
7. Before the provider can pay you the proceeds from the life settlement contract, the
provider needs to be notified by the life insurer or group administrator that the
ownership of the policy or the interest in the certificate of insurance has been
transferred, and that the beneficiary has been designated according to the terms of
the life settlement contract. The provider is required to pay you the proceeds from
the life settlement contract within three business days after the provider has received
the insurer or group administrator's notification.
8. The provider should tell you the date by which the monies will be available to you and
the transmitter of the monies.
9. The provider or the broker or its authorized representative may periodically contact
the insured to determine the insured's health status or to verify the insured's address.
This contact is limited to once every three months if the insured has a life
expectancy of more than one year, and is limited to once per month if the
insured has a life expectancy of one year or less.
10. Attached to this disclosure document is Form P-LSA: Life Settlement Affiliations,
which provides information about the broker, and notifies you of affiliations or
contractual relations between the provider and the broker, and any affiliation between
the provider and the issuer of the policy to be settled.
11. A broker represents you exclusively and not the insurer or the provider or any other
person. The broker owes a fiduciary duty to you, including a duty to act according to
your instructions and in your best interest.
All medical, financial or personal information solicited or obtained by a provider or
broker about an insured, including the insured's identity or the identity of family
members, a spouse or a significant other, may be disclosed as necessary to effect the
life settlement contract between you and the provider. If you are asked to provide this
information, you will be asked to consent to the disclosure. The information may be
provided to someone who buys the policy or provides monies for the purchase. You
may be asked to renew your permission to share information every two years.
Any person who knowingly presents false information in an application for insurance
or life settlement contract is guilty of a class 1 misdemeanor and may be subject to
fines and confinement in jail.
Signature required by ARS § 20-3204(A). By signing this form, you acknowledge that you
read and understand the information contained on this disclosure document. If you need
legal advice, you should consult an attorney.
►Owner/Seller Signature:
Date
►Provider/Broker Signature:
Date
Life Settlement Provider/Broker Disclosures to Owner
FORM P-LSA: LIFE SETTLEMENT AFFILIATIONS
BROKER INFORMATION
Name of Life Settlement Broker (“Broker”) AZ Insurance License No.
Business Address City State ZIP Code
PROVIDER INFORMATION
Name of Life Settlement Provider (“Provider”) AZ Insurance License No.
Provider’s Representative (if the Provider is not an individual)
BROKER AND PROVIDER AFFILIATIONS OR CONTRACTUAL RELATIONS
Description of affiliations or contractual relations between Broker and Provider
PROVIDER AND ISSUER AFFILIATION
Name of Life Insurer (“Issuer”) NAIC Number
Description of affiliation, if any, between Provider and Issuer
►Provider/Broker Signature: Date
Form P-LSA (9/17/2013)
Form P-LSBD (9/17/2013)
FORM P-LSBD: LIFE SETTLEMENT BROKER
DISCLOSURES TO OWNER AND PROVIDER
BROKER INFORMATION
Name of Life Settlement Broker Telephone Number
Business Address City State ZIP code
LIFE INSURANCE POLICY OWNER/SELLER INFORMATION
First Name Middle Name Last Name Jr/Sr/III/etc.
PROVIDER INFORMATION
Name of Life Settlement Provider
Provider Representative (if provider is not an individual)
Pursuant to Arizona law, the broker of a Life Settlement Contract must provide to both the
owner and provider certain disclosures in writing before all parties sign the life settlement
contract. I, as the broker of the proposed life settlement contract, have attached the
following required disclosures:
1. A full, complete and accurate description of all of the offers, counteroffers,
acceptances and rejections relating to the proposed life settlement contract.
2. Any affiliations or contractual arrangements between me, as broker, and any person
making an offer in connection with the proposed life settlement contract.
3. The name of each broker who will receive compensation and the amount of
compensation received by that broker including anything of value paid or given to the
broker in connection with the life settlement contract.
4. A complete reconciliation of the life settlement provider’s gross offer or bid to the net
amount of proceeds or value that you, the owner, will receive. For the purposes of
this paragraph, "gross offer or bid" means the total amount or value offered by the
provider for the purchase of one or more life insurance policies including
commissions and fees.
SIGNATURES: By signing this form, you acknowledge that you have been provided all of
the above-listed required disclosures.
►Owner Signature __________________________________ Date_______________
►Provider Signature _________________________________ Date_______________
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

2013 03 Regulatory Bulletin 2013-03 (Arizona)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 1 July 2022

Message

View Audit Log
Print With Audit Log
Duplicate Document