Fillable Florida Viatical & Life Settlement Application Form (Welcome Funds)

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Florida Viatical & Life Settlement Application Form (Welcome Funds)

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WELCOME FUNDS INC.
4755 TECHNOLOGY WAY
SUITE 202
BOCA RATON, FL 33431
TOLL-FREE: 877.227.4484
PHONE: 561.862.0244
FAX: 561.862.0242
WWW.WELCOMEFUNDS.COM
State of Florida
Life Insurance Agency License
WELCOME FUNDS INC.
4755 TECHNOLOGY WAY
SUITE 202
BOCA RATON, FL 33431
TOLL-FREE: 877.227.4484
PHONE: 561.862.0244
FAX: 561.862.0242
WWW.WELCOMEFUNDS.COM
TABLE OF CONTENTS
Document Title Page #(s)
Evaluation Request for Sale of Existing Life Insurance
Insured’s Personal Information 1 of 4
Policy Information & Policy Owner Information 2 of 4
Financial Information
(Signature(s) Required) 3 of 4
Personal Acknowledgements
(Signature(s) Required) 4 of 4
Notice of Disclosure (Signature(s) Required) 1 of 1
Authorization for Release of Policy Information (Signature(s) Required) 1 of 1
Authorization for the Disclosure of Protected Health Information/Primary Insured (Signature(s) Required) 1 of 1
Authorization for the Disclosure of Protected Health Information/Secondary Insured (Signature(s) Required) 1 of 1
Viatical Settlement Broker and/or Advisor Authorization & Services Agreement (Signature(s) Required) 1 of 1
NAIC (National Association of Insurance Commissioners) Brochure 1 – 2
ADDITIONAL DOCUMENT CHECKLIST
Please include the following documents, if available, with your Evaluation Request to significantly decrease the time necessary to
facilitate the potential sale of your policy. If you cannot provide the items below, then Welcome Funds Inc will attempt to obtain
items A & B with the authority granted from the signed authorizations contained herein. Items C through H must be obtained
through your own efforts.
□ A. Current In Force Illustrations for Each Policy (please confirm desired/required illustrations with Welcome Funds Inc).
□ B. Complete Medical History Dating Back at least Two (2) Years Prior to the Issuance of the Policy for Each Insured.
□ C. Photocopy of Two Forms of Identification (ie. Drivers License, SS Card, Passport etc...) for Each Insured & Policy Owner.
□
D. Photocopy of Applicable Insurance Policy/Policies
(including applications for insurance).
□ E. Photocopy of Trust or Corporate Formation Documents (if applicable).
□ F. Photocopy of Divorce Decree of Insured & Policy Owner (if applicable).
□ G. Photocopy of Bankruptcy Discharge of Insured & Policy Owner (if applicable).
□ H. Photocopy of All Premium Finance Documents (if applicable).
FORM WFI.CHECK.EF3/10; © 2010 Welcome Funds Inc ____________
Viator’s Initials
WELCOME FUNDS INC.
4755 TECHNOLOGY WAY
SUITE 202
BOCA RATON, FL 33431
TOLL-FREE: 877.227.4484
PHONE: 561.862.0244
FAX: 561.862.0242
WWW.WELCOMEFUNDS.COM
EVALUATION REQUEST FOR SALE OF EXISTING LIFE INSURANCE
Welcome Funds Inc. is a life agency in Florida with a license number of L035366.
Daniel Ohman, license number E191171, is a viatical settlement broker and the life agent in charge of the Agency.
The information provided below shall be used to evaluate, underwrite and generate
conditional offers for the sale of your life insurance policy.
PRIMARY INSURED’S PERSONAL INFORMATION
PRIMARY INSURED NAME (AS LISTED WITH LIFE INSURANCE CARRIER) DATE OF BIRTH SOCIAL SECURITY NUMBER
CURRENT HOME ADDRESS TELEPHONE NUMBER
CITY STATE ZIP CODE
PRIMARY ATTENDING PHYSICIAN SPECIALTY CITY/STATE DATE LAST SEEN TELEPHONE NUMBER
OTHER PHYSICIANS SEEN IN LAST 5 YEARS SPECIALTY CITY/STATE DATE LAST SEEN TELEPHONE NUMBER
OTHER PHYSICIANS SEEN IN LAST 5 YEARS SPECIALTY CITY/STATE DATE LAST SEEN TELEPHONE NUMBER
HOSPITAL (S) NAME, ADDRESS, TELEPHONE NUMBER THAT HAS TREATED YOU IN THE LAST 24 MONTHS FOR YOUR ILLNESS
PLEASE PROVIDE A BRIEF DESCRIPTION OF YOUR MEDICAL HISTORY
SECONDARY INSURED’S PERSONAL INFORMATION (IF APPLICABLE – SURVIVORSHIP ONLY)
SECONDARY INSURED NAME (AS LISTED WITH LIFE INSURANCE CARRIER) DATE OF BIRTH SOCIAL SECURITY NUMBER
CURRENT HOME ADDRESS TELEPHONE NUMBER
CITY STATE ZIP CODE
PRIMARY ATTENDING PHYSICIAN SPECIALTY CITY/STATE DATE LAST SEEN TELEPHONE NUMBER
OTHER PHYSICIANS SEEN IN LAST 5 YEARS SPECIALTY CITY/STATE DATE LAST SEEN TELEPHONE NUMBER
OTHER PHYSICIANS SEEN IN LAST 5 YEARS SPECIALTY CITY/STATE DATE LAST SEEN TELEPHONE NUMBER
HOSPITAL (S) NAME, ADDRESS, TELEPHONE NUMBER THAT HAS TREATED YOU IN THE LAST 24 MONTHS FOR YOUR ILLNESS
PLEASE PROVIDE A BRIEF DESCRIPTION OF YOUR MEDICAL HISTORY
Family Member Spouse Business Partner Other:________________________
PLEASE CHECK APPICABLE RELATIONSHIP TO PRIMARY INSURED (IF APPLICABLE)
If there are additional physicians or if there is additional medical information,
then please attach a separate sheet with complete details.
FORM WFI.EF3/10; © 2010 Welcome Funds Inc ____________
Viator’s Initials
- 1 -
FORM WFI.EF3/10; © 2010 Welcome Funds Inc ____________
Viator’s Initials
- 2 -
LIFE INSURANCE POLICY INFORMATION
LIFE INSURANCE COMPANY POLICY NUMBER ISSUE DATE
FACE AMOUNT TOTAL POLICY LOAN AMOUNT CASH SURRENDER VALUE
Individual Joint Survivorship Group Other______________________________________________
TYPE OF POLICY (PLEASE CHECK ONE)
IF A GROUP POLICY, PLEASE PROVIDE NAME, ADDRESS, AND TELEPHONE NUMBER OF THE CONTACT WITH THE ISSUING GROUP
Term WL UL Other:_____________________________________________
CLASSIFICATION OF POLICY (PLEASE CHECK ONE)
Annually Semi-Annually Quarterly Monthly $_________________________________
POLICY PREMIUM PAYMENT (PLEASE CHECK THE APPROPRIATE BOX) PREMIUM AMOUNT
PLEASE PROVIDE THE NAMES AND RELATIONSHIP OF ALL PRIMARY BENEFICIARIES OF THE POLICY (IF IT IS A TRUST, PROVIDE NAME AND ADDRESS OF TRUSTEE)
ADDITIONAL BENEFICIARIES AND/OR CONTINGENT BENEFICIARIES
POLICY OWNER INFORMATION
EXACT NAME OF POLICY OWNER (INDIVIDUAL / CORP. / TRUST - AS LISTED WITH LIFE INSURANCE CARRIER) SOCIAL SECURITY OR TAX ID NUMBER
POLICY OWNER ADDRESS (ADDRESS / STATE OF DOMICILE OF INDIVIDUAL / CORP. / TRUST) TELEPHONE NUMBER
CITY STATE ZIP CODE
EXACT NAME OF CORPORATE OFFICER(S) / TRUSTEE(S) (IF CORPORATE / TRUST OWNED POLICY) DATE OF INCORPORATION / TRUST
IF THERE ARE MULTIPLE POLICY OWNERS, THEN PLEASE LIST ALL NAMES AND STATES OF RESIDENCE
IF THERE ARE MULTIPLE POLICY OWNERS, THEN PLEASE LIST ALL NAMES AND STATES OF RESIDENCE
Family Member Spouse Business Partner Policy Owner is Insured Other: ___________________
IF POLICY OWNER IS AN INDIVIDUAL, THEN PLEASE CHECK APPICABLE RELATIONSHIP TO INSURED
Single Married Widowed Legally Separated Divorced – Date: __________
IF POLICY OWNER IS AN INDIVIDUAL, THEN PLEASE CHECK MARITAL STATUS
YES NO YES NO Date:______________________
HAS POLICY OWNER EVER DECLARED BANKRUPTCY? IF SO, HAS IT BEEN DISCHARGED? WHEN WAS IT DISCHARGED?
For multiple policies, please photocopy this page, complete the above information
and sign new insurance authorizations for each policy.
FORM WFI.EF3/10; © 2010 Welcome Funds Inc ____________
Viator’s Initials
- 3 -
FINANCIAL INFORMATION (REQUIRED FOR SUITABILITY REVIEW)
I. PLEASE DESCRIBE REASONS FOR CONSIDERING THE SALE OF POLICY(IES), CHECK ALL THAT APPLY:
No longer require or want to pay for the life coverage Planning to lapse, cancel, or surrender the policy
Health & living expenses are a financial burden Considering a 1035 Exchange or replacement policy
Interested in learning market value of policy Cash liquidity preferred due to current financial situation
Other or provide further details: __________________________________________________________________________________
All Policy Owner(s) and Insured(s) please sign at the bottom of the page, regardless of whether you complete all of the financial
information below.
Please be advised that any Policy Owner(s) and/or Insured(s) who declines to provide full and complete financial data acknowledges and
accepts responsibility that such lack of data will impede Welcome Funds Inc’s ability to provide recommendations it deems suitable,
based on personal and specific financial needs, conditions and situations.
Check here if you choose NOT to complete some or all of the requested financial information below (and sign below).
II. INVESTMENT PROFILE (PLEASE USE COMBINED FIGURES FOR JOINT ACCOUNTS):
INVESTMENT OBJECTIVES: Capital Preservation Income Capital Appreciation/Growth Speculation
(check all that apply)
POLICY OWNER’S TAX BRACKET: 10% 15% 25% 28% 33% 35%
POLICY OWNER’S NET WORTH: $0 - $49,999 $50,000 - $99,999 $100,000 - $199,999 $200,000 - $499,999
$500,000 - $999,999 $1,000,000 - $2,499,999 $2,500,000 and up
ESTIMATED INSURABLE CAPACITY FOR INSURED(S): $________________________________________________________
TOTAL AMOUNT OF IN-FORCE LIFE INSURANCE COVERING INSURED(S): $_____________________________________
III. PLEASE CERTIFY THE CURRENT ACCREDITED INVESTOR STATUS OF THE POLICY OWNER:
THE POLICY OWNER IS CONSIDERED AN ACCREDITED INVESTOR: YES NO
(Refer to the definitions below to answer the above question and if “yes,” then please check the appropriate description)
________
INDIVIDUALS:
1. An individual that has a net worth or joint net worth, with the individual’s spouse, in excess of $1,000,000. “Net worth” for these
purposes is defined as the value of total assets at fair market value, including but not limited to home, home furnishings and
automobiles, less total liabilities; or
________
2. An individual that (i) had income (exclusive of any income attributable to the individual’s spouse) of more than $200,000 for
each of the past two years or joint income with the individual’s spouse in excess of $300,000 in each of those years, and (ii)
reasonably expects to reach the same individual income level, or the same joint income level, as the case may be, in the current
year; or
________
ENTITIES:
3. A corporation, partnership, limited liability company, Massachusetts or similar business trust or tax-exempt organization as
defined in Section 501(c)(3) of the Code, that (i) has total assets in excess of $5,000,000, and (ii) was not formed for the specific
purpose of investing in the life insurance policy and then selling it; or
________
4. A revocable trust which may be amended or revoked at any time by the grantors thereof, and of which all of the grantors are
accredited investors under either (1) or (2) above; or
________
5. A trust (i) that has total assets in excess of $5,000,000, (ii) that was not formed for the specific purpose of acquiring the life
insurance policy and then selling it, and (iii) whereby the investment decisions are directed by a person who has such knowledge
and experience in business and financial matters and who can evaluate the merits and risks of its investments; or
________
6. A trust for which a bank or savings and loan association is acting as fiduciary in directing investment decisions; or
________
7. An entity whose equity owners are each “accredited investors” i.e., persons meeting the requirements set forth in either of (1) or
(2) above.
Verified and Confirmed By:
___________________________________________ _________________________________ ________
Signature of Primary Insured Printed Name Date
___________________________________________ _________________________________ ________
Signature of Secondary Insured (if applicable) Printed Name Date
___________________________________________ _________________________________ ________
Signature of Policy Owner #1 (if not Insured) Printed Name Date
___________________________________________ _________________________________ ________
Signature of Policy Owner #2 (if not Insured) Printed Name Date
FORM WFI.EF3/10; © 2010 Welcome Funds Inc ____________
Viator’s Initials
- 4 -
PERSONAL ACKNOWLEDGEMENTS
I. Do you have a referring viatical settlement broker and/or advisor authorized, on your behalf, to a) represent your interests
regarding this Evaluation Request & potential transaction; & b) accept & decline offers, if any, for the sale of your existing
life insurance policy?
Yes No
If yes, then please provide the name(s) of such referring advisor(s) and/or viatical settlement broker(s) below:
____________________________________________________ _____________________________________________________
Name of Referring Viatical Settlement Broker and/or Advisor #1 Name of Referring Viatical Settlement Broker and/or Advisor #2 (if applicable)
II. Have you signed a Power of Attorney (POA) granting a legal representative to act on your behalf or do you have a
Guardian ad Litem or similar legal representative acting on your behalf regarding this Evaluation Request & Potential
Transaction?
Primary Insured: Yes No Policy Owner #1: Yes No
Secondary Insured (if applicable): Yes No Policy Owner #2 (if applicable): Yes No
If yes, then please 1) attach the applicable legal documents to this Evaluation Request; 2) have the legal representative of
the insured sign the “Authorization for Disclosure of Protected Health Information” forms for the primary and secondary
insured as applicable; and 3) provide the names of such legal representative(s) below:
__________________________________________________ __________________________________________________
Name of Legal Representative of Primary Insured (if applicable) Name of Legal Representative of Policy Owner #1 (if applicable)
__________________________________________________ __________________________________________________
Name of Legal Representative of Secondary Insured (if applicable) Name of Legal Representative of Policy Owner #2 (if applicable)
III. How did you learn about the option to sell your life insurance policy?
Through my/our own knowledge/research Through my/our referring viatical settlement broker
and/or advisor
IV. Was this life insurance policy premium financed?
Yes No
If yes, then please 1) attach all finance documents, including contracts, trusts and/or corporate documents etc…in order to
evaluate and determine the validity and legality of this potential transaction for insurable interest; 2) provide the name of
the financing company: _____________________________________________________.
Name of Financing Company (if applicable)
A. I/We represent that the information contained in this Evaluation Request for Sale of Existing Life Insurance is correct and
accurate and acknowledge that WELCOME FUNDS INC may rely on such information, including but not limited to the Personal
Acknowledgements above. I/we will immediately notify WELCOME FUNDS INC of any changes.
B. I/We give my/our consent to WELCOME FUNDS INC, its agents and/or authorized representatives to release and/or transmit
electronically all financial and insurance information gathered from this Evaluation Request for Sale of Existing Life Insurance,
including but not limited to medical records, notes and lab reports pertaining to the insured’s health, to the appropriate parties who
have an identifiable need to facilitate the sale of my/our life insurance policy(ies).
C. I/We acknowledge that this Evaluation Request for Sale of Existing Life Insurance may become part of the contract for the sale
of my/our policy if my/our life insurance policy(ies) is/are purchased. In addition, I/we have been advised that I/we may obtain a
copy, upon request, of any written agreement that I/we enter into regarding or relating to the sale of my/our life insurance
policy(ies).
D. I/We believe that that selling my/our life insurance policy is in my/our best interest based on my/our understanding of selling
existing life insurance policies, my/our current financial situation and my/our prior investment experience and objectives.
Acknowledged By:
___________________________________________ _________________________________ ________
Signature of Primary Insured Printed Name Date
___________________________________________ _________________________________ ________
Signature of Secondary Insured (if applicable) Printed Name Date
___________________________________________ _________________________________ ________
Signature of Policy Owner #1 (if not Insured) Printed Name Date
___________________________________________ _________________________________ ________
Signature of Policy Owner #2 (if not Insured) Printed Name Date
FORM WFI.FLDISC.EF3/10; © 2010 Welcome Funds Inc ____________
Viator’s Initials
WELCOME FUNDS INC.
4755 TECHNOLOGY WAY
SUITE 202
BOCA RATON, FL 33431
TOLL-FREE: 877.227.4484
PHONE: 561.862.0244
FAX: 561.862.0242
WWW.WELCOMEFUNDS.COM
NOTICE OF DISCLOSURE
1. WELCOME FUNDS INC and your referring viatical
settlement broker, if any, represents only you and shall act
according to your instructions and in your best interest
notwithstanding the manner in which WELCOME FUNDS
INC and your referring viatical settlement broker, if any, is
com
p
ensated.
2. Some or all of the proceeds of your viatical settlement may be
taxable under federal income tax and/or state franchise and
income tax laws. WELCOME FUNDS INC is not a tax
advisor and recommends that you consult your own
professional tax advisor regarding this transacti
on.
3. The sale of your insurance policy may affect your right to
receive Medicaid or other government benefits
or
entitlements. Advice on such effects should be obtained from
the appropriate government agencies.
4. In a
ddition, viatical settlement proceeds could be subject to
the claims of creditors.
5. There may be possible alternatives to selling your life
insurance. This may include the option of an accelerated death
benefit or policy loans offered by your life insurance
company. You are advised to consult a financial advisor,
certified public accountant and/or an attorney regarding these
potential alternatives.
6. Once you have received your proceeds from the sale of your
life insurance policy, you will have fifteen (15) days from
receipt of the viatical settlement proceeds in which to re
scind
the transaction. If the insured dies during the rescission period,
then the viatical settlement contract shall be deemed
rescinded, subject to repayment of all viatical settlement
procee
ds.
7. You will receive proceeds from the viatical settlement
transaction pursuant to the provisions of the viatical settlement
contract after the insurer or group administrator’
s
acknowledgment that ownership of the policy or interest in the
certificate has been transferred and the beneficiary has been
d
esignated. WELCOME FUNDS INC and your referrin
g
viatical settlement broker, if any, has no access to or control
over viatical settlement provider funds that are set aside in
escrow or trust.
8. You have the right to know the name, business address, and
phone number of the entity that serves as the independen
t
third-party escrow agent that disburses your viatical settlement
proceeds. In addition, you may inspect or receive copies of th
e
relevant escrow or trust agreements or documents.
9. Entering into a viatical settlement contract may 1) cause other
ri
ghts or benefits, including conversion rights and waiver of
premium benefits, which may exist under the policy or a
certificate of a group life insurance policy to be forfeited; and 2)
reduce the insured’s ability to obtain additional life insurance
coverage in the future.
10. Total compensation payable to WELCOME FUNDS INC and
your referring viatical settlement broker, if any, shall collectively
not exceed a maximum of 8% of the Net Death Benefit (NDB) of
your policy. Proceeds of your viatical settlement are represented
by the Net Purchase Price (NPP) as follows: NPP = Gross
Purchase Price (GPP) as paid by the viatical settlement provid
er
reduced by the total compensation as described above.
11. All medical, financial or personal information solicited or
obtained by a viatical settlement provider, WELCOME FUNDS
INC. and/or a referring viatical settlement broker about th
e
insured, including the insured’s identity or the identity of family
members, a spouse or significant other may be disclosed as
necessary to effect the viatical settlement between you and th
e
viatical settlement provider. The information may be presented to
someone who buys the policy or provides funds for the purchase.
Check your viatical settlement contract to see if and when
your
permission to share this information may be requested. In
addition, information regarding the policy owner’s and insured’s
identity and insured’s medical condition will 1) be shared with
the insurer that issued the life insurance policy; and 2) shall be
available to each subsequent owner of the life insurance policy.
12. The insured may be contacted by the viatical settlement provid
er
or WELCOME FUNDS INC or its authorized representative for
the purpose of determining the insured’s health status. The
viatical settlement contract will define the contact limitations in
de
tail.
13. Any
person who knowingly presents false information in an
ap
p
lication for a viatical settlement contract is guilty of a crime
subject to penalty, including fines and imprisonment.
14. WELCOME FUNDS INC recommends that
you read the viatical
settlement contract and seek assistance from a professional
financial advisor and/or consult with your legal advisor prior to
signing it.
15. I/we confirm and acknowledge that WELCOME FUNDS INC
has provided me/us with the most recent brochure develope
d
and/or approved by the National Association of Insurance
Commissioners (NAIC) describing the process of viatical
settlements.
I/We acknowledge that I/we have read and understand the disclosures above (1-15).
___________________________________________ _________________________________ ________
Signature of Primary Insured Printed Name Date
___________________________________________ _________________________________ ________
Signature of Secondary Insured (if applicable) Printed Name Date
___________________________________________ _________________________________ ________
Signature of Policy Owner #1 (if not Insured) Printed Name Date
___________________________________________ _________________________________ ________
Signature of Policy Owner #2 (if not Insured) Printed Name Date
WELCOME FUNDS INC.
4755 TECHNOLOGY WAY
SUITE 202
BOCA RATON, FL 33431
TOLL-FREE: 877.227.4484
PHONE: 561.862.0244
FAX: 561.862.0242
WWW.WELCOMEFUNDS.COM
AUTHORIZATION FOR THE RELEASE OF LIFE INSURANCE POLICY INFORMATION
_________________________________________ __________________________________________
Life Insurance Company Policy Number
_________________________________________ __________________________________________
Printed Name of All Policy Owner(s) Printed Name of Insured(s)
I/we (the undersigned individual(s)) hereby authorize the above-referenced life insurance company and/or any other entity or
person that has information related to the above-referenced life insurance policy to release such information to and reply
immediately to any written, telephonic or other request for information or documents required by WELCOME FUNDS INC
and/or its authorized representatives pertaining to the above-referenced life insurance policy that I/we own.
I/we under
stand and specifically authorize the release of information by this form to include any and all LIFE INSURANCE
POLICY OR CERTIFICATE information, including but not limited to: applications for insurance, forms, riders,
illustrations, conversions, current values, verification of coverage, contestable and suicide status, lapse or reinstatement
application and history and amendments concerning the policy or certificate, confirmation and status of change in ownership
designations and any other general information about my coverage.
WELCOME FUNDS INC makes it hereby known that the policy owner has the right to withdraw consent to this Release of
Life Insurance Policy Information at any time, pursuant to applicable law. I/we understand that WELCOME FUNDS INC
will keep all information disclosed hereunder confidential and will only use the information provided for the purpose of
evaluating my life insurance coverage, determining my eligibility for sale of my life insurance policy and facilitating the
potential sale of my life insurance policy. Furthermore, I/we understand that WELCOME FUNDS INC will not release any
information to any person or organization except as may be otherwise lawfully required or as I/we may further authorize.
I/we certify that I/we am/are executing and delivering this Authorization freely and unilaterally/collectively as of the date
written below. I/we further certify that I/we have a full understanding of the Authorization’s contents and I/we will retain a
completed copy for future reference. I/we specifically authorize and request that this Authorization for the Release of Life
Insurance Policy Information shall remain valid until the death of the Insured or until the case is declined by WELCOME
FUNDS INC, absent any provision of any applicable state statute or regulation to the contrary, in which event it shall remain
valid for the maximum period permitted thereunder and that a photocopy or facsimile of this document is as valid as an
original. This document may also be signed in counterparts.
Authorized By:
___________________________________________ _________________________________ ________
Signature of Policy Owner #1 Printed Name Date
___________________________________________ _________________________________ ________
Signature of Policy Owner #2 (if any) Printed Name Date
FORM WFI.INSAUTH.EF3/10; © 2010 Welcome Funds Inc
____________
Viator’s Initials
WELCOME FUNDS INC.
4755 TECHNOLOGY WAY
SUITE 202
BOCA RATON, FL 33431
TOLL-FREE: 877.227.4484
PHONE: 561.862.0244
FAX: 561.862.0242
WWW.WELCOMEFUNDS.COM
AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION
I, __________________________________ (the undersigned individual/primary insured), DOB____________SS#_________________,
hereby authorize disclosure, as defined under the privacy regulations promulgated pursuant to the Health Insurance Portability and
Accountability Act of 1996, of my protected health information (“PHI”) as follows:
1. Classes of Persons Authorized to Disclose My PHI. I authorize each doctor, hospital, laboratory, nurse, pharmacy, pharmacy
benefits manager, physician, physician practice group, insurance organization and any other type of health care provider (each, an
“Authorized HCP”) having any PHI about me to disclose any and all of my PHI as provided under this authorization. I authorize
each Authorized HCP to rely upon a photostatic or facsimile copy or other reproduction of this authorization.
2. Classes of Persons Authorized to Receive My PHI. I authorize each Authorized HCP to disclose my PHI under this authorization
to WELCOME FUNDS INC including a) any of its affiliates, agents, subsidiaries, corporate parents, independent contractors,
consultants, service providers and authorized representatives and the officers, directors and employees of each, and b) to any other
person or entity required or compelled by law to receive or view such PHI to evaluate, facilitate, underwrite and solicit bids for the
sale of my life insurance policy(ies), including but not limited to medical underwriters, lenders, financing entities, buyers of life
insurance policies, life expectancy providers and stop-loss re-insurers and his or their affiliates, agents, subsidiaries, corporate
parents, independent contractors, consultants, service providers and authorized representatives and the officers, directors and
employees of each (each, an “Authorized Recipient”). I understand that my PHI may be secured by and electronically transmitted to
an Authorized Recipient, including but not limited to transmission via e-mail and posting to a password protected, secure website.
3.
Description of PHI Authorized for Disclosure and Purpose of Disclosure. This authorization shall apply to any and all of my
health and medical data, information and reco
rds, whether or not personally or individually identifiable or protected under any
federal or state confidentiality or privacy laws or regulations. This authorization and all disclosures of my PHI made under this
authorization are for purposes of allowing the Authorized Recipient to a) evaluate and/or underwrite my health status or life
expectancy; and/or b) monitor, track or verify my health status in connection with any life insurance policy under which my life is
insured that an Authorized Recipient, or any other person or entity, purchases. I hereby authorize the disclosure of my health
information as described above. I understand the information disclosed may include information relating to Acquired
Immunodeficiency Syndrome (AIDS), Human Immunodeficiency Virus (HIV), sexually transmitted diseases, psychiatric care,
mental health services, genetic testing, and/or treatment for alcohol and drug abuse.
4. Expiration of Authorization. This authorization shall remain valid until, and shall expire, one year after the date of my death or the
maximum period as allowed by state or federal law.
5. Right to Revoke Authorization. I acknowledge and understand that I may revoke this authorization any time with respect to any
Authorized HCP by notifying such Authorized HCP in writing of my revocation of this authorization and delivering my revocation
by mail or personal delivery at such address designated to me by such Authorized HCP; provided, that, any revocation of this
authorization shall not apply to the extent that the Authorized HCP has taken action in reliance upon this authorization prior to
receiving written notice of my revocation.
6. Inability to Condition Treatment, Payment, Enrollment or Eligibility for Benefits on Provision of Authorization. No
Authorized HCP or other covered entity may condition my treatment, payment, enrollment or eligibility for benefits on whether I sign
this authorization.
I understand that a) this Authorization is not a consent or an authorization requested by a health care provider, health care clearinghouse
or health plan covered by the privacy regulations promulgated pursuant to the Health Insurance Portability and Accountability Act of
1996 (the “HIPAA Privacy Regulations”); b) as a result of this Authorization, there is the potential for my PHI that is disclosed by any
Authorized HCP to an Authorized Recipient to be subject to re-disclosure by the Authorized Recipient and my PHI that is disclosed to
such Authorized Recipient may no longer be protected by the HIPAA Privacy Regulations; and c) my ongoing health status may be
tracked as a result of this Authorization.
I certify that I am executing and delivering this authorization freely and unilaterally and that all information contained in this
authorization is true and correct. I further certify that this authorization is written in plain language and that I have received and retained a
copy of this signed authorization for future reference.
____________________________________________________________________________________________
List of Authorized Disclosers (AD) (Hospitals, Doctors, Etc.):
‘
Authorized by:
___________________________________________ _________________________________ ________
Signature of Individual (Primary Insured) Printed Name Date
___________________________________________ _________________________________ ________
Signature of Legal Representative of Primary Insured (if any) Printed Name Date
Description of Legal Representative’s Authority (if any): _______________________________________________________________________________________________
(POA, Guardian ad Litem or similar status – Please attach legal documents for verification)
FORM WFI.
HIPAA1.EF3/10; © 2010 Welcome Funds Inc
WELCOME FUNDS INC.
4755 TECHNOLOGY WAY
SUITE 202
BOCA RATON, FL 33431
TOLL-FREE: 877.227.4484
PHONE: 561.862.0244
FAX: 561.862.0242
WWW.WELCOMEFUNDS.COM
AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION
I, __________________________________ (the undersigned individual/second insured), DOB____________SS#_________________,
hereby authorize disclosure, as defined under the privacy regulations promulgated pursuant to the Health Insurance Portability and
Accountability Act of 1996, of my protected health information (“PHI”) as follows:
1. Classes of Persons Authorized to Disclose My PHI. I authorize each doctor, hospital, laboratory, nurse, pharmacy, pharmacy
benefits manager, physician, physician practice group, insurance organization and any other type of health care provider (each, an
“Authorized HCP”) having any PHI about me to disclose any and all of my PHI as provided under this authorization. I authorize
each Authorized HCP to rely upon a photostatic or facsimile copy or other reproduction of this authorization.
2. Classes of Persons Authorized to Receive My PHI. I authorize each Authorized HCP to disclose my PHI under this authorization
to WELCOME FUNDS INC including a) any of its affiliates, agents, subsidiaries, corporate parents, independent contractors,
consultants, service providers and authorized representatives and the officers, directors and employees of each, and b) to any other
person or entity required or compelled by law to receive or view such PHI to evaluate, facilitate, underwrite and solicit bids for the
sale of my life insurance policy(ies), including but not limited to medical underwriters, lenders, financing entities, buyers of life
insurance policies, life expectancy providers and stop-loss re-insurers and his or their affiliates, agents, subsidiaries, corporate
parents, independent contractors, consultants, service providers and authorized representatives and the officers, directors and
employees of each (each, an “Authorized Recipient”). I understand that my PHI may be secured by and electronically transmitted to
an Authorized Recipient, including but not limited to transmission via e-mail and posting to a password protected, secure website.
3.
Description of PHI Authorized for Disclosure and Purpose of Disclosure. This authorization shall apply to any and all of my
health and medical data, information and records,
whether or not personally or individually identifiable or protected under any
federal or state confidentiality or privacy laws or regulations. This authorization and all disclosures of my PHI made under this
authorization are for purposes of allowing the Authorized Recipient to a) evaluate and/or underwrite my health status or life
expectancy; and/or b) monitor, track or verify my health status in connection with any life insurance policy under which my life is
insured that an Authorized Recipient, or any other person or entity, purchases. I hereby authorize the disclosure of my health
information as described above. I understand the information disclosed may include information relating to Acquired
Immunodeficiency Syndrome (AIDS), Human Immunodeficiency Virus (HIV), sexually transmitted diseases, psychiatric care,
mental health services, genetic testing, and/or treatment for alcohol and drug abuse.
4. Expiration of Authorization. This authorization shall remain valid until, and shall expire, one year after the date of my death or the
maximum period as allowed by state or federal law.
5. Right to Revoke Authorization. I acknowledge and understand that I may revoke this authorization any time with respect to any
Authorized HCP by notifying such Authorized HCP in writing of my revocation of this authorization and delivering my revocation
by mail or personal delivery at such address designated to me by such Authorized HCP; provided, that, any revocation of this
authorization shall not apply to the extent that the Authorized HCP has taken action in reliance upon this authorization prior to
receiving written notice of my revocation.
6. Inability to Condition Treatment, Payment, Enrollment or Eligibility for Benefits on Provision of Authorization. No
Authorized HCP or other covered entity may condition my treatment, payment, enrollment or eligibility for benefits on whether I sign
this authorization.
I understand that a) this Authorization is not a consent or an authorization requested by a health care provider, health care clearinghouse
or health plan covered by the privacy regulations promulgated pursuant to the Health Insurance Portability and Accountability Act of
1996 (the “HIPAA Privacy Regulations”); b) as a result of this Authorization, there is the potential for my PHI that is disclosed by any
Authorized HCP to an Authorized Recipient to be subject to re-disclosure by the Authorized Recipient and my PHI that is disclosed to
such Authorized Recipient may no longer be protected by the HIPAA Privacy Regulations; and c) my ongoing health status may be
tracked as a result of this Authorization.
I certify that I am executing and delivering this authorization freely and unilaterally and that all information contained in this
authorization is true and correct. I further certify that this authorization is written in plain language and that I have received and retained a
copy of this signed authorization for future reference.
____________________________________________________________________________________________
List of Authorized Disclosers (AD) (Hospitals, Doctors, Etc.):
‘
Authorized by:
_________________________________ ________ ___________________________________________
Signature of Individual (Second Insured)
Printed Name Date
_________________________________ ________ ___________________________________________
Signature of Legal Representative of Second Insured (if any)
Printed Name Date
Description of Legal Representative’s Authority (if any): _______________________________________________________________________________________________
(POA, Guardian ad Litem or similar status – Please attach legal documents for verification)
FORM WFI.HIPAA2.EF3/10; © 2010 Welcome Funds Inc
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Florida Viatical & Life Settlement Application Form (Welcome Funds)

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Completed 26 June 2021

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