Fill - Free fillable FORM P-LSC: CONTRACT CHECKLIST: Life & Health Division (Arizona) PDF form

Form P-LSC (9/26/2013) Page 1 of 4

Life & Health Division

Arizona Department of Insurance

2910 North 44

Street, Suite 210

Phoenix, AZ 85018-7269

LIFE SETTLEMENT PROVIDER

FORM P-LSC: CONTRACT CHECKLIST

Name of Life Settlement Provider

Officer/Member Name

Title E-mail Address Phone Number

This checklist must be submitted with your filing in compliance with ARS § 20-3203. This list includes the relevant statutory cites. Review of the

entire statute or rule may be necessary. Complete each item to confirm that diligent consideration has been given to each and is certified by the

signature on the certificate of compliance form. Any line left blank will cause this filing to be considered incomplete and will be subject to rejection.

Not including required information or policy provisions will result in disapproval of the filing. This filing must be filed through the System for

Electronic Rate and Form Filing (“SERFF”), accessible from http://www.serff.org.

The requirements for life settlements are under ARS § 20- 3201 through 20-3215 and ARS § 20-2106, which are accessible from the Internet at

http://www.azleg.gov/ArizonaRevisedStatutes.asp?Title=20

TOI (type of insurance) code: LSO1 Life Settlement

Item Reference Review Requirements Description of review standards requirements

Form #,

Page #,

Paragraph #

Acknowledge

1 ARS § 20-3203(C) Filing settlement contract

A person may not use a life settlement contract form

in this state unless the form is first filed with and

approved by the director.

2 ARS § 20-3203(C) Filing of disclosure statement

A person may not provide to an owner a disclosure

statement form in this state unless the form is first

filed with and approved by the director.

If the director-pre-approved form P-LSDO is used to

meet this requirement, the provider or broker does not

need to file it with the Department before using.

yes if using

director-pre-

approved

disclosure form

P-LSDO

LIFE SETTLEMENT PROVIDER – CONTRACT CHECKLIST

Form P-LSC (9/26/2013) Page 2 of 4

Item Reference Review Requirements Description of review standards requirements

Form #,

Page #,

Paragraph #

Acknowledge

3 ARS § 20-3204(C)

Broker disclosures to owner and

provider

Disclosures in subsections (C)(1)-(5) shall be clearly

displayed in the life settlement contract or in a

separate signed document.

If the director-pre-approved form P-LSBD is used to

meet this requirement, the broker does not need to file

it with the Department before using.

yes if using

director-pre-

approved

disclosure form

P-LSBD

ARS § 20-3211

(A)(1)

Owner-insured physician

statement

If the owner is the terminally ill insured, a written

statement from a licensed attending physician that the

owner is of sound mind and under no constraint or

undue influence to enter into a settlement contract.

acknowledge

provider receipt

requirement

ARS § 20-3211

(A)(2)

(A.R.S. § 20-2106)

Insured’s consent to release of

medical records

A document in which the terminally ill insured

consents to the release of the insured's medical

records to a provider, settlement broker or insurance

producer and, if the policy was issued less than two

years from the date of application for a settlement

contract, to the insurance company that issued the

policy.

NOTE: The form must meet the requirements listed in

ARS § 20-2106.

acknowledge

provider receipt

requirement

6 ARS § 20-3211(C)

Owner written consent to

settlement contract

Before or at the time of execution of the settlement

contract, the provider shall obtain a witnessed

document in which the owner consents to the

settlement contract, represents that the owner has a

full and complete understanding of the settlement

contract and a full and complete understanding of the

benefits of the policy, acknowledges that the owner is

entering into the settlement contract freely and

voluntarily and, for persons with a chronic illness or

terminal illness or condition, acknowledges that the

insured has a chronic illness or a terminal illness or

condition and that the chronic illness or the terminal

illness or condition was diagnosed after the policy was

issued.

LIFE SETTLEMENT PROVIDER – CONTRACT CHECKLIST

Form P-LSC (9/26/2013) Page 3 of 4

Item Reference Review Requirements Description of review standards requirements

Form #,

Page #,

Paragraph #

Acknowledge

7 ARS § 20-3211(G)

Written notice to insurer of

settlement contract

Within twenty days after an owner executes the life

settlement contract, the provider shall give written

notice to the insurer that issued the insurance policy

that the policy is subject to a life settlement contract.

The notice shall be accompanied by the documents

required by section 20-3204, subsection C.

Provider

acknowledges

this

requirement

8 ARS § 20-3211(H)

(A.R.S. § 20-2106)

Medical record confidentiality

All medical information solicited or obtained by any

licensee is subject to any applicable law relating to

confidentiality of medical information.

Provider

acknowledges

this

requirement

9 ARS § 20-3211(I) Owner right to rescind

All life settlement contracts entered into in this state

shall provide that the owner may rescind the contract

on or before fifteen days after the date it is executed

by all parties and the owner has received all required

disclosures.

10 ARS § 20-3211(J)

Provider payment of proceeds to

escrow account

Within three business days after the provider receives

from the owner documents to effect the transfer of the

insurance policy, the provider shall pay the proceeds

of the settlement to an escrow or trust account

managed by a trustee or escrow agent in a state or

federally chartered financial institution pending

acknowledgment of the transfer by the issuer of the

policy.

11 ARS § 20-3211(K) Failure to tender proceeds

Failure to tender the life settlement contract proceeds

to the owner by the date disclosed to the owner

renders the contract voidable by the owner for lack of

consideration until the time the proceeds are tendered

to and accepted by the owner. The failure to give

written notice of the right of rescission tolls the right of

rescission until thirty days after the written notice of

the right of rescission has been given.

LIFE SETTLEMENT PROVIDER – CONTRACT CHECKLIST

Form P-LSC (9/26/2013) Page 4 of 4

Item Reference Review Requirements Description of review standards requirements

Form #,

Page #,

Paragraph #

Acknowledge

12 ARS § 20-3211(L) Computation of fees paid

Any fee paid by a provider, party, individual or owner

to a broker in exchange for services provided to the

owner pertaining to a life settlement contract shall be

computed as a percentage of the offer obtained and

not the face value of the policy. This section does not

prohibit a broker from reducing the broker's fee below

this percentage if the broker so chooses.

13 ARS § 20-3211(M)

Broker disclosure of value

paid/given

The broker shall disclose to the owner anything of

value paid or given to a broker that relates to a life

settlement contract.

14 ARS § 20-3211(V) Fraud statement

The location of the statement, “Any person who

knowingly presents false information in an application

for insurance or for a life settlement contract may be

subject to criminal or civil liability.”

CERTIFICATION

I, _______________________________________, certify to the best of my knowledge and belief that this checklist and each form involved with

this filing

 conforms to all the applicable requirements presented in this checklist; and,

 contains no provision previously disapproved or required to be corrected or revised by the Arizona Department of Insurance; and,

 does not exceed the provider’s powers, the authority granted by its state of domicile, or the authority granted by its Arizona certificate of

authority.

►Signature of Officer: __________________________________________ Date:____________________

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