Fillable Financial Affairs Division Arizona Department of Insurance (Arizona)

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Financial Affairs Division Arizona Department of Insurance (Arizona)

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Form E-LSPS (v. 20180716) Page 1 of 3
Financial Affairs Division
Arizona Department of Insurance
100 North 15th Avenue, Suite 102
Phoenix, AZ 85007-2624
LIFE SETTLEMENT PROVIDER
ANNUAL STATEMENT
FOR THE YEAR ENDING
December 31, ________
AZ # (see Certificate of Authority):
Life Settlement Provider Name
Federal Employer Identification
Number (FEIN)
Alternate (Assumed) Name / DBA
HOME OFFICE Street Address
City
State
ZIP Code
MAILING Address
City
State
ZIP Code
Main Phone
FAX Number
Type of Entity (select only one)
Stock Corporation
Individual
Partnership
Limited Liability Company
Other (Describe): ____________________________________________
State Where Incorporated/Formed
Fiscal Year Ends on
December 31
Other (mm/dd) : _____/_____
CONTACT
PERSON
Name
E-mail Address
Street Address
City
State
ZIP Code
Toll-free Phone
Main Phone
FAX Number
Annual Statement Filing Fee
Provide a check made payable to the Arizona Department of Insurance in the amount of $300 for non-refundable annual statement
filing fee. ARS § 20-167(A)(8).
Financial Condition
Attach a balance sheet and income statement showing the life settlement provider’s financial condition at the year end of the preceding
calendar year. ARS § 20-3210(A).
Ownership Information
Complete Form E-LSP2 with information for each stockholder or owner of the provider except for stockholders owning less than 10% of
the shares of the provider whose shares are publicly traded, partners, officers and employees. Pursuant to ARS § 20-3202(C), you
must provide an updated version of this form within 30 days of a change to the information provided.
Management Information
Complete Form E-LSP3 with information for each officer, director, member, and partner, and for each designated employee who shall
be authorized to act under the life settlement provider certificate of authority. Submit NAIC Form 11: Biographical Affidavit for each
person listed on Form E-LSP3 form whom Form 11 has not previously been provided. Obtain Form 11 from
http://www.naic.org/industry_ucaa.htm.
A person may not act on behalf of the provider unless the person has been named on this form as part of the application for the certificate of authority or
as a supplement to the application. ARS § 20-3202(D). Report changes by submitting an updated Form E-LSP3 executed by an officer, director,
member, or partner of the provider, along with NAIC Form 11 for each new person listed.
Reset
LIFE SETTLEMENT PROVIDER
ANNUAL STATEMENT (cont.)
Form E-LSPS (v. 20180716) Page 2 of 3
FOR THE YEAR ENDING
December 31, ________
AZ # (see Certificate of Authority):
Life Settlement Provider Name
Federal Employer Identification
Number (FEIN)
Policy Information. Provide information relating to the immediately preceding calendar year (in other words, enter information for the year ending December 31
that you specified above). Complete additional pages if information for all policy issue years does not fit on one page. Do not include individual transaction data or
information that could be used to identify any owner or insured. ARS § 20-3210(A).
Policy Issue
Year
Nationwide
Arizona only
Total number of
policies settled
during the year
Aggregate face value of
policies settled during
the year
Life settlement
proceeds of policies
settled during the year
Total number of
policies settled
during the year
Aggregate face value
of policies settled
during the year
Life settlement
proceeds of policies
settled during the year
TOTAL
0
$ 0
0
0
$ 0
0
LIFE SETTLEMENT PROVIDER
ANNUAL STATEMENT (cont.)
Form E-LSPS (v. 20180716) Page 3 of 3
ATTESTATION AND CERTIFICATION
By signing this form, the signatories solemnly swear, attest and certify, under penalty of perjury, to all the
following:
All information contained in the annual statement and any attachments, enclosures and supplements
thereto, are true, complete and accurate, to the best of the knowledge and belief of the signatories.
ARS § 20-3210(A).
The life settlement provider, and each of its officers, directors, members, partners and designated
employees who shall have authority to act under the certificate of authority issued to the life
settlement provider understand they must comply with ARS §§ 20-3201 et seq. and other Arizona
laws pertinent to acting as a life settlement provider including but not limited to the following
provisions:
Privacy requirements set forth in ARS §§ 20-3205, 20-3211(H), 20-2101 et seq. and applicable
federal laws;
Annual statement requirements set forth in ARS § 20-3210;
Requirements for viatical and life-settlement contracts set forth in ARS § 44-1841 et seq. (esp.
ARS § 44-1850);
Requirements to only use licensed life settlement brokers to perform life settlement broker
activities. ARS § 20-3202(I).
_________________________________________ _________________________________________
Signature Date
_________________________________________ _________________________________________
Printed Name Title
_________________________________________ _________________________________________
Signature Date
_________________________________________ _________________________________________
Printed Name Title
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Financial Affairs Division Arizona Department of Insurance (Arizona)

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Completed 12 August 2020

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