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_______________
