Fillable FORM P-LSA: LIFE SETTLEMENT AFFILIATIONS: Life Settlement Provider/Broker (Arizona)

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FORM P-LSA: LIFE SETTLEMENT AFFILIATIONS: Life Settlement Provider/Broker (Arizona)

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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)
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FORM P-LSA: LIFE SETTLEMENT AFFILIATIONS: Life Settlement ProviderBroker (Arizona)

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Completed 12 August 2020

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