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
