Fillable Life Settlement Application Form - For Connecticut Residents (Welcome Funds)

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Life Settlement Application Form - For Connecticut Residents (Welcome Funds)

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FORM WFI.WELCOME.EF2/08 © 2008 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
LETTER FROM THE PRESIDENT
Dear Policy Owner/Insured:
Thank you for choosing WELCOME FUNDS INC to help you determine and identify the merits and value of
selling your policy. We understand that the process can be intimidating and overwhelming and it is our job to
not only maximize the sales value of your policy(ies) in the secondary market, but also to provide a seamless,
transparent and fully informed experience. Please complete our Evaluation Request for Sale of Existing Life
Insurance and sign the appropriate pages.
As your designated broker who represents your best interests and follows your instructions, WELCOME
FUNDS INC incurs the necessary, required and related costs to facilitate the potential sale of your policy related
to the following services:
• Evaluation Form assessme
nt.
• Medical underwriting and insurance verifications.
• Obtaining and forwarding independent third party life expectancy reports.
• Submission to multiple authorized and/or registered buyers of life insurance policies.
• Best execution negotiation to maximize fair market value of the sale of your policy.
• Closing services including contract review and assistance with contingency requirements of buyers of
life insurance policies.
Please re
ad the Notice of Disclosure and the Broker Authorization and Services Agreement carefully and sign
accordingly. These pages represent the first step in explaining your rights and obligations associated with the
process. With that said, you are under no obligation to accept any contingent offers secured by WELCOME
FUNDS INC. Furthermore, we have attached a brief brochure issued by the National Association of Insurance
Commissioners (NAIC), a non-profit organization of insurance regulators from all 50 states, to provide an
unbiased, independent description of selling policies in the secondary market. Please read the NAIC material as
well.
Please be advised that the personal information acquired shall only be shared with individuals and entities with
an identifiable need to help determine the market value of your policy, including but not limited to life
expectancy underwriters and potential buyers of your policy. All parties involved in the analysis, evaluation,
underwriting and contingent pricing for transactions are required to maintain strict privacy and confidentiality
safeguards pursuant to applicable state and federal regulations.
Once again thank you for allowing us the opportunity to help you reach your financial goals and to represent
you in the secondary market for the potential sale of your life insurance policy.
Sincerely,
John M. Wel
c
o
m
President
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 Connecticut
Life Settlement Broker 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
EVALUATION REQUEST FOR SALE OF EXISTING LIFE INSURANCE
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.EF5/08 © 2008 Welcome Funds Inc
- 1 -
FORM WFI.EF5/08 © 2008 Welcome Funds Inc
- 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.
___________________________________________
Signature of Policy Owner #2 (if not Insure d)
FORM WFI.EF5/08
© 2008 Welcome Funds Inc
- 3 -
ADDITIONAL INFORMATION
I. PLEASE DESCRIBE REASONS FOR CONSIDERING T
HE 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 rep
lacement policy
Interested in learning market value of policy Cash liquidity preferred due to current financ
ial 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 non-primary residence home (the
value of the primary residence, as of July, 2010, is excluded), 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
_________________________________ ________
Printed Name Date
FORM WFI.EF5/08 © 2008 Welcome Funds Inc
- 4 -
PERSONAL ACKNOWLEDGEMENTS
I. Do you have a referring advisor/broker authorized, on your behalf, to a) represent your interests regarding this Evaluation
Request & potential transaction; & b) to accept offers, if any, for the sale of your existing life insurance policy?
Yes No
If Yes, then please provide the name(s) of such advisor(s)/broker(s) below:
____________________________________________________ _____________________________________________________
Name of Referring Advisor /Broker #1 Name of Referring Advisor/Broker #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: (if not Insured): 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 insurance policy?
Through my/our own knowledge and/or research and asked to receive this Evaluation Request.
Through my/our referring advisor/broker.
IV. Was this 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)
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.
I/We give my/our consent to WELCOME FUNDS INC, its agents and/or authorized representatives to release and/or tra
nsmit
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.
I/We further acknowledge that this Evaluation Request for Sale of Existing Life Insurance may become part of my contract for the
sale of my existing life insurance policy if my/our life insurance policy is 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).
‘
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.CTDISC.EF10/08 © 2008 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
NOTICE OF DISCLOSURE
1. WELCOME FUNDS INC and your referring advisor/broker, if any,
represents you exclusively and not the insurer, the life settlement
provider or any other person and owes a fiduciary duty to you,
including a duty to act according to your instructions and in your best
interest notwithstanding the manner in which WELCOME FUNDS
INC and your referring advisor/broker, if any, is compensated.
2. Some or all of the proceeds of the life settlement contract may be
taxable. WELCOME FUNDS INC is not a tax advisor and
recommends that you seek assistance from a professional tax advisor
regarding this transaction.
3. Receipt of the life settlement contract proceeds may adversely affect
your eligibility for public assistance or other government benefits or
entitlements and advice should be obtained from the appropriate
agencies.
4. Proceeds from the life settlement contract could be subject to the
claims of creditors.
5. The life settlement provider may assign or otherwise transfer its
interest in the settled policy to a third party.
6. There are possible alternatives to life settlement contracts including
but not limited to accelerated death benefits policy offered by the
issuer of the life insurance policy. You are advised to consult a
financial advisor, certified public accountant and/or an attorney
regarding these potential alternatives.
7. You have the right to rescind a life settlement contract for fifteen
(15) calendar days after (i) the date such contract is executed by all
parties; and (ii) you have received the disclosures specified herein.
Such rescission shall be effective only if both notice of rescission is
given to the life settlement provider and you repay all proceeds and
any premiums, loans and loan interest paid by the life settlement
provider within the rescission period. If the insured dies during the
rescission period, then the settlement contract shall be deemed
rescinded, subject to you or your estate’s repayment of all settlement
proceeds and any premiums, loans and loan interest to the life
settlement provider.
8. Proceeds from the life settlement contract will be sent to you within
three (3) business days after the life settlement provider has received
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 designated in accordance with the terms of the
life settlement contract. WELCOME FUNDS INC and your referring
advisor/broker, if any, has no access to or control over life settlement
provider funds that are set aside in escrow or trust.
9. Entering into a life settlement contract and the subsequent change of
ownership may 1) cause other rights 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 – assistance should be sought from a financial advisor; and
2) limit the insured’s ability to purchase future life insurance
coverage because there is a limit to how much coverage insurers will
issue on one life.
10. Total compensation payable to both WELCOME FUNDS INC and your
referring advisor/broker, if any, shall collectively be calculated as a
percentage of the contingent offer obtained for the sale of your existing
life insurance policy. Your proceeds are represented by the Net Purchase
Price (NPP) as follows: NPP = Gross Purchase Price (GPP) as paid by
the life settlement provider reduced by the total compensation as
described above. Actual total compensation shall be disclosed no later
than the date the life settlement contract is signed by all parties.
11. All medical, financial or personal information solicited or obtained by a
life settlement provider or WELCOME FUNDS INC. about the 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
life settlement contract between the owner and the life settlement
provider. If you are asked to provide this information, you will be asked
to consent to this disclosure. The information may be presented to
someone who buys the policy or provides funds for the purchase. You
may be asked to renew your permission to share information every two
(2) years. 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 life settlement provider or
WELCOME FUNDS INC or its authorized representative for the
purpose of determining the insured’s health status or to verify the
insured’s address. This contact will be limited to no more frequently
than once every three (3) months if the insured has a life expectancy of
more than one year, and no more than once per month if the insured has
a life expectancy of one (1) year or less.
13. You have the right to know the (i) date by which funds will be available
to you and the transmitter of such funds; (ii) affiliation, if any, between
the life settlement provider and the issuer of the insurance policy to be
settled; (iii) name, address and telephone number of the life settlement
provider; and (iv) name, address and telephone number of the
independent third party escrow agent. In addition, you may inspect or
receive copies of the relevant escrow or trust agreements or documents.
14. Any person who knowingly presents false information in an application
for insurance or for a life settlement contract is guilty of a crime and
may be subject to fines and confinement in prison.
15. WELCOME FUNDS INC recommends that you read the life settlement
contract and seek assistance from a professional financial advisor and/or
consult with your legal advisor prior to signing it.
16. I/we confirm and acknowledge that WELCOME FUNDS INC has
provided me/us with the most recent brochure developed and/or
approved by the National Association of Insurance Commissioners
(NAIC) describing the process of life settlements.
I/We acknowledge that I/we have read and understand the disclosures above (1-16
).
___________________________________________ _________________________________ ________
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 u
nderstand 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.EF2/08 © 2008 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/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
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 (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.EF5/08 © 2008 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.EF5/08 © 2008 Welcome Funds Inc
FORM WFI.CTNONXBROKERAUTH.EF10/08 © 2008 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
BROKER AUTHORIZATION & SERVICES AGREEMENT
Do you have a referring advisor/broker working with WELCOME FUNDS INC and authorized to a) represent your interests
regarding this Evaluation Request & potential transaction; & b) accept offers, if any, on your behalf?
Yes No If Yes, then please provide the name(s) of such advisor(s)/broker(s) below:
____________________________________________________ _____________________________________________________
Name of Referring Advisor /Broker #1 Name of Referring Advisor/Broker #2 (if applicable)
WELCOME FUNDS INC works exclusively in the secondary market for life insurance by representing the best interests of
consumers and maximizing the sales value of their policy(ies). As your designated broker, WELCOME FUNDS INC incurs the
necessary, required and related costs to facilitate the sale of your policy while providing the following services including but not
limited to:
● E
valuation Form assessment. ● Medical
underwriting & insurance verifications.
● Obtaining and forwarding independent ● Submission to multiple authorized and/or registered
third party life expectancy reports. buyers of life insurance policies.
● Best execution negotiation to maximize ● Closing services including contract review & assistance with
fair market value of the sale of your policy. contingency requirements of buyers of life insurance policies.
In consideration of the services provided and related costs incurred as described above, I/We authorize WELCOME FUNDS INC
to act as my
/our broker and to evaluate, underwrite, solicit, generate and secure conditional offers beginning on the date of
execution of this Agreement and continuing for 180 days after the final offer is obtained/acquired regarding and/or related to the
purchase of the following life insurance policy(ies):
1
st
Policy No. ___________ issued by ____________________. 2
nd
Policy No. ___________ issued by ____________________.
Name of Insurance Carrier (if applicable) Name of Insurance Carrier
Furthermore, by signing this authorization and agreement, I/we am/are:
1. Granting to WELCOME FUNDS INC the authority, for the period of time described above, to evaluate, underwrite,
solicit, generate and secure conditional and appropriate offers as determined by WELCOME FUNDS INC pursuant to its
typical business model, methods and practices, for the sale of my/our life insurance policy(ies) as stated above.
2. Reco
gnizing the proprietary nature of such appropriate, conditional o
ffers as evaluated, underwritten, solicited, generated
and secured by WELCOME FUNDS INC for the period of time as described above and pursuant to this Broker
Authorization & Services Agreement.
3. Agreeing to the total compensation, as described in this paragraph, payable to WELCOME FUNDS INC and your referring
advisor/broker, if any. Suc
h compensation shall collectively be calculated as a percentage of the contingent offer obtained for
the sale of your existing life insurance policy. Your proceeds are represented by the Net Purchase Price (NPP) as follows:
NPP = Gross Purchase Price (GPP) as paid by the life settlement provider reduced by the total compensation as described
above. Actual total compensation shall be disclosed no later than the date the life settlement contract is signed by all parties.
4. Aware th
at WELCOME FUND
S INC issues no guarantee that my/our life insurance policy will be sold, is under no
obligation to purchase my/our policy or to ultimately find a buyer of my/our policy(ies) and is not responsible for any
breach committed by a buyer if one is identified.
Agreed to & Accepted 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
___________________________________________ _________________________________ ________
Signature of Authorized Officer of WELCOME FUNDS INC Printed Name Date
Selling Your Life
Insurance Policy:
Understanding Life
Settlements
Defining the Terms
· Do I still need life insurance protection?
· Will I qualify for a new life insurance policy
in the future?
· If I sell my policy, how will they decide how
much cash I get?
· If I sell my policy, will there be any costs I
have to pay?
· If I sell my policy, will the money be put into
an escrow account? If so, who will the
escrow agent be? Does state law
require the agent to be licensed?
· Is my policy an employer or other
group policy? If so, do I need their
permission to sell it?
· If I sell my policy, who will be the legal
owner?
· Is the viatical settlement provider I plan to
sell to allowed to do business in my state?
· After I sell my policy, can the buyer resell it?
Additional Questions to
Consider
A life settlement is the sale of a life insurance
policy to another person or company in return for a
cash payment of less than the full amount of the
death benefit.
A life settlement provider is the person or
company that becomes the new policy owner in
return for a payment made to the seller. The life
settlement provider becomes the policy owner,
must pay any premiums that are due, and eventu-
ally collects the full amount of the death benefit
from the insurance company.
A life settlement broker is the person or
company who represents the seller of the policy
and can comparison shop for life settlement offers.
The buyer pays the broker a commission if the sale
is completed.
· If you’re asked to invest in or buy a
life settlement, contact your state
insurance department to learn more
about the issues and risks.
· If you don’t have a life-threatening
illness and you’re interested in
selling your life insurance policy,
contact your state insurance depart-
ment for more information.
· If you’ve been contacted by some-
one who wants you to buy a policy
and then sell it immediately, contact
your state insurance department.
This activity may be considered
fraudulent and the parties may be
prosecuted by the appropriate
authorities.
Consumer Alert
This publication was issued in joint cooperation with the:
National Association of Insurance Commissioners
2301 McGee Street, Suite 800
Kansas City, Mo. 64108
(816)842-3600
http://www.naic.org
Check with Your State
Your state insurance department may regulate
the purchase of life settlements. Contact them
for a copy of those regulations.
A life settlement is the sale of a life insurance
policy to a third party. The owner of a life insurance
policy sells it for a cash payment that is less than the
full amount of the death benefit. The buyer becomes
the new owner and/or beneficiary of the life insurance
policy, pays all future premiums and collects the full
amount of the death benefit when the insured dies.
People decide to sell their life insurance policies
for many reasons. When an individual with a terminal
or chronic illness sells his or her life insurance policy,
that is known as a viatical settlement. When an
individual who does not have a terminal or chronic
illness sells a policy for other reasons, including
changed needs of dependents, wanting to reduce
premiums, and cash for meeting expenses, that is
known as a life settlement.
A life settlement may or may not be the right
choice for you. Your state insurance department, along
with the National Association of Insurance Commis-
sioners, is concerned that many consumers may not
fully understand life settlements. Please continue
reading before making any decisions.
Understanding
Life Settlements
· Understand how the process works and
when the different phases will happen.
· Decide whether to sell your policy
directly to a life settlement provider or
go through a life settlement broker
who will do the comparison shopping
for you.
· If you don’t use a life settlement
broker, comparison shop on your own.
· You don’t have to accept any life
settlement offer.
· Check all application forms for accu-
racy, especially information about your
medical history.
· You must be truthful in your answers to
application questions.
· Make sure the life settlement provider
agrees to put your settlement proceeds
in escrow with an independent party or
financial institution to make sure your
funds are safe during the transfer.
· Find out if you have the right to change
your mind about the life settlement
offer after you get the proceeds. In
many states, you have the right to
change your mind for a certain period
of time. If you have that right, you’ll
have to return the money you were paid
and premiums the buyer paid.
· Understand whether buyers may learn
your identity when they buy your
policy, and whether they will know
certain medical and personal informa-
tion about you, such as your address
and life expectancy.
Consumer Tips
Get All of the Facts
Before you enter into any life settlement
transaction, you should:
· Contact your life insurer to learn about all of
your possible options under your policy.
· Contact a life settlement broker or life settle-
ment provider for information about life
settlements.
· Consult with your own financial
advisor who knows your personal
financial needs. Be sure to ask
about tax and other financial
consequences if you sell your policy.
· Contact your state insurance department for
information about current laws that may protect
you.
· Find out if you have any cash value in your
life insurance policy. You may be able to
use some of the cash value to meet your
immediate needs and keep
your policy in force for your
beneficiaries without having
to sell it to a third party. You
may also be able to use the cash
value as security for a loan from a financial
institution.
· Review other sources of cash that may meet
your financial needs at a lower cost than a
life settlement.
Consider All Your Options
Other Considerations
· Contact a professional tax advisor. Find
out the tax implications. Proceeds are
only tax-free under certain circum-
stances.
· Know that your creditors could claim the
proceeds.
· Find out if you’ll lose any public assistance
benefits such as food stamps or Medicaid if
you get a cash settlement.
· Know that you must provide certain
medical and personal information to third
parties who will be paid the proceeds from
your policy upon your death. These third
parties may sell your policy and pass along
your medical and personal information to
other individuals.
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Life Settlement Application Form - For Connecticut Residents (Welcome Funds)

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Completed 26 June 2021

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