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

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Life Settlement Application Form - For Kansas Residents (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 Kansas
Agency License & Individual Viatical Settlement Broker License
Kansas does not license entities for Viatical or Life Settlements, therefore Welcome Funds is a licensed Producer Entity and
transactions are facilitated through the Officer’s Viatical Settlement Broker License.
FORM WFI.WELCOME.EF1/16 © 2016 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
A LETTER FROM THE FOUNDER
De
ar Policy Owner/Insured:
As Founder & CEO of Welcome Funds, I would personally like to thank you for considering our team to serve as your
personal representative in the secondary market for life insurance. We understand that you have choices in this process
and we appreciate the opportunity to represent you. We also know that selling your life insurance policy is an important
financial decision for you and your family, and our goal is to ensure that you are able to make this choice with confidence.
Welcome Funds is the one of the oldest and largest life settlement brokers in the United States and has assisted thousands
of Americans since our founding in 2000. As your broker, we work diligently to represent your best interests during the
entire transaction, from initial evaluation through the closing process. Our procedures consist of the following:
• Initial evaluation and review to determine eligibility;
• Evaluation Request assessment and processing;
• Medical records requests and life insurance policy verifications;
• Obtaining independent third party life expectancy report(s);
• Submission to authorized and/or state licensed secondary market buyers of life insurance policies;
• Best execution negotiations via an auction process in an effort to maximize the sales price of your policy;
• Closing services including contract review and assistance with closing contingency requirements.
In addition to the traditional procedure and lump sum cash settlements offered by the secondary market, we are also able to
provide alternative options that you may want to consider, depending on your personal needs:
1. Expedited Bid Process – for situations that require a fast turnaround time due to the possibility of a lapse or a
personal financial crisis;
2. Retained Death Benefit Offers – an offer to purchase the policy that includes a beneficiary of your choice
maintaining some death benefit, with the buyer paying all future premiums. This can include a combination of a cash
payout & retaining a portion of the death benefit. This option may not be available in all states or for all policies; or
3. Life Insurance Loans – if you are interested in a loan using your life insurance policy as collateral, we can also work
with multiple lending firms to secure financing. A loan option may not be available in all states or for all policies.
Please be sure to inform your advisor or your case manager if you would like to consider any of the above options. We
would also like to recommend that you discuss the tax consequences of selling your life insurance policy with a tax
advisor, as it is likely a taxable event, unless the insured qualifies for a viatical settlement or long-term care exemption in
compliance with IRS codes. Additionally, we have attached a brief brochure for your review issued by the Kansas
Insurance Department titled, "Selling Your Life Policy" to provide an unbiased, independent description of
selling policies in the secondary market.
As a reminder, you are under no obligation to sell your life insurance policy, in fact, if you need your coverage and can
afford to maintain it, we highly recommend that you do so!
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,
Joh
n M. Welcom
Founder & CEO
FORM WFI.EF1/16 © 2016 Welcome Funds Inc
- 1 -
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
This request is not an agreement to purchase your policy and you are under no obligation to sell your policy by completing this form.
The information that you provide in this request shall be used to evaluate and prepare your file, as required, to attempt to
negotiate and secure a conditional offer or offers for the potential sale of your existing life insurance policy.
PRIMARY INSURED’S INFORMATION
PRIMARY INSURED NAME (FULL LEGAL NAME) DATE OF BIRTH SOCIAL SECURITY NUMBER TELEPHONE NUMBER
CURRENT HOME ADDRESS 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
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
Single
Married
Divorced
Widowed
PLEASE CHECK APPICABLE MARITAL STATUS IF MARRIED/DIVORCE/WIDOWED, PLEASE PROVIDE FULL NAME OF (EX)SPOUSE
SECONDARY INSURED’S INFORMATION
(If Applicable – 2
ND
To Die / Survivorship Policies Only)
SECONDARY INSURED NAME (FULL LEGAL NAME) DATE OF BIRTH SOCIAL SECURITY NUMBER TELEPHONE NUMBER
CURRENT HOME ADDRESS 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
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 medical information, then please attach a separate sheet with complete details.
FORM WFI.EF1/16 © 2016 Welcome Funds Inc
- 2 -
LIFE INSURANCE POLICY INFORMATION
LIFE INSURANCE COMPANY FACE AMOUNT POLICY NUMBER ISSUE DATE
YES
NO
POLICY LOAN AMOUNT (IF ANY) ACCUMULATED/CASH VALUE (IF ANY) CASH SURRENDER VALUE (IF ANY) CASH VALUE USED TO PAY PREMIUMS?
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 OR YOUR HR DEPT. CONTACT
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 NAMES AND RELATIONSHIP OF ALL PRIMARY BENEFICIARIES OF POLICY (IF IT IS A TRUST, PROVIDE TRUST NAME AND NAME & ADDRESS OF TRUSTEE(S))
ADDITIONAL BENEFICIARIES AND/OR CONTINGENT BENEFICIARIES
POLICY OWNER INFORMATION
If Individually Owned (if Insured is 100% Owner, skip to Bankruptcy Status):
LEGAL NAME OF POLICY OWNER # 1 RELATIONSHIP TO INSURED SOCIAL SECURITY NUMBER
POLICY OWNER # 1 ADDRESS CITY STATE ZIP CODE TELEPHONE NUMBER
LEGAL NAME OF POLICY OWNER # 2 (IF APPLICABLE) RELATIONSHIP TO INSURED SOCIAL SECURITY NUMBER
POLICY OWNER # 2 ADDRESS CITY STATE ZIP CODE TELEPHONE NUMBER
IF THERE ARE MORE INDIVIDUAL 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 A POLICY OWNER EVER DECLARED BANKRUPTCY? IF SO, HAS IT BEEN DISCHARGED? (PLEASE PROVIDE ALL BANKRUPTCY DOCS) WHEN WAS IT DISCHARGED?
If Corporate or Trust Owned:
LEGAL NAME OF COMPANY OR TRUST RELATIONSHIP TO INSURED TAX ID NUMBER
COMPANY OR TRUST ADDRESS (OFFICIAL DOMICILE) CITY STATE ZIP CODE TELEPHONE NUMBER
LEGAL NAME OF AUTHORIZED COMPANY OFFICER OR TRUSTEE # 1 LEGAL NAME OF AUTHORIZED COMPANY OFFICER OR TRUSTEE # 2
TRUSTEE # 1 ADDRESS (IF DIFFERENT THAN TRUST) CITY STATE ZIP CODE TELEPHONE NUMBER
TRUSTEE # 2 ADDRESS (IF DIFFERENT THAN TRUST) CITY STATE ZIP CODE TELEPHONE NUMBER
For multiple policies, please reprint this page, then complete the above information and sign an insurance authorization form for each policy.
FORM WFI.EF1/16 © 2016 Welcome Funds Inc
- 3 -
ADDITIONAL INFORMATION
PLEASE PROVIDE REASONS FOR INTEREST IN SELLING POLICY(IES), CHECK ALL THAT APPLY:
Planning to lapse, cancel, or surrender the policy
Proceeds from sale will help pay for medical treatments
Health & living expenses are a financial burden
Considering a 1035 Exchange or replacement policy
Premium costs have become unaffordable
Cash liquidity preferred due to current financial situation
Original purpose of policy no longer exists
Higher estate tax exemptions has eliminated need for policy
Other or provide further details: _____________________________________________________________________________
PLEASE VERIFY LEGAL CAPACITY OF POLICY OWNER(S) & INSURED(S):
If you choose to accept a contingent offer as a result of this preliminary application process, each individual Policy Owner(s)
and Insured(s) may be required to have a Letter of Competency completed by an attending physician in order to verify their
legal capacity to enter into an agreement to sell the life insurance policy. If the legal capacity of any party is questionable, we
recommend obtaining an official Power of Attorney or Guardian ad Litem for that signatory as soon as possible.
Is there an existing Power of Attorney (POA) granting a legal representative the authority to act on behalf of a signatory or is there
a Guardian ad Litem or similar legal representative acting on their 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) provide a full copy of the applicable legal documents (Durable POA or Medical POA) to verify the authority to sign on
behalf of the signatory;
2) have the legal representative sign all signature lines for that party; 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)
PLEASE VERIFY SOURCE OF PREMIUM PAYMENTS AND/OR ASSIGNMENT OF POLICY:
1) Did the policy owner use a third-party to finance the premium payments? Yes No
If Yes, then please:
a) attach all loan documents, including contracts, trusts and/or corporate documents; and
b) provide the name of the lender/financing company: __________________________________________________
Name of Lender/Financing Company
2) Is the life insurance policy being used as collateral for a loan or is there a current lien or assignment recorded with the life
insurance carrier?
Ye
s
No
If Yes, please provide all loan documents & name of lienholder/assignee: __________________________________________
Name of Lienholder/Assignee
PLEASE VERIFY YOUR MARKET REPRESENTATION:
Are you working with any other third-party, other than Welcome Funds, related to the potential sale of your life insurance policy?
Yes No
If Yes, please check all that apply:
Financial Advisor
Life Agent
Attorney/CPA
Settlement Broker
Direct Buyer
Direct Lender
FORM WFI.EF1/16 © 2016 Welcome Funds Inc
- 4 -
PERSONAL ACKOWLEDGEMENTS
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 as my/our broker for the
potential sale of my/our life insurance policy. I/we also acknowledge that it is my/our responsibility to notify
WELCOME FUNDS INC of any changes to this information, including any changes in health of the insured after this
form has been submitted.
B. I/We understand that the market value of my/our life insurance policy is based in part on the health status and life
expectancy of the insured. Current medical records for the insured are vital to obtain life expectancy assessments. These
assessments are conducted by independent third-party life expectancy providers as required by the marketplace.
WELCOME FUNDS INC is not responsible for the conclusions of these life expectancy providers and does not have the
expertise to dispute those conclusions.
C. I/We acknowledge that WELCOME FUNDS INC is my/our broker who represents my/our best interests during the entire
transaction process. I/We also understand and acknowledge that WELCOME FUNDS INC issues no guarantee that an
offer will be secured for my/our policy.
D. I/We give my/our consent to WELCOME FUNDS INC, its agents and/or authorized representatives to release and/or
transmit electronically all financial, insurance, medical and personal 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 review the information.
E. I/We acknowledge that this Evaluation Request for Sale of Existing Life Insurance may become part of my/our contract
for the sale of my/our existing life insurance policy if my/our 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 existing life insurance policy(ies).
F. I/We acknowledge that I/we have been provided the following address/department to direct any consumer complaints
that I/we may have: WELCOME FUNDS INC c/o Customer Complaints, to 4755 Technology Way – Suite 202, Boca
Raton, FL 33431.
G. I/We understand and acknowledge that WELCOME FUNDS INC does not provide any advice as to whether or not to
proceed with the sale of my/our life insurance policy and I/we are free to accept or decline any offer.
H. I/We understand and acknowledge that the policy owner is fully responsible for the timely payment of any and all
premiums due for the policy that is the subject of this potential transaction, on the applicable due dates, up until change
of ownership of the policy occurs, if a transaction is effectuated. I/We, not WELCOME FUNDS INC, assume sole
responsibility if the policy lapses for failure to make timely payment of any and all premiums.
I. I/We would like to consider the following options in addition to a lump sum cash settlement offer (subject to availability
based on state residency, policy types and qualification requirements):
Retained Death Benefit (RDB) Cash Settlement with RDB Life Insurance Loan/Credit Line
Expedited Bid Program (may require additional disclosures)
Fraud Warning: Any person who knowingly presents false information in an application for insurance or a
viatical/life settlement contract is guilty of a crime & may be subject to fines & confinement in prison.
I/We acknowledge that I/we have read and understand the information provided above.
___________________________________________ _________________________________ ________
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 applicable & if not Insured) Printed Name Date
FORM WFI.KSDISC.EF7/08 © 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
KANSAS -- NOTICE OF DISCLOSURE
1. WELCOME FUNDS INC and your referring advisor/broker,
if any, represents only you exclusively, not the insurer or the
viatical/life settlement provider, and owes a fiduciary duty to
you including the 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 your viatical/life 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 transaction.
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. Viatical/life 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) calendar days
from receipt of the viatical/life settlement proceeds in which
to rescind the transaction. If the insured dies during the
rescission period, then the settlement contract shall be deemed
rescinded, subject to repayment of all settlement proceeds and
any premiums, loans and loan interest to the viatical/life
settlement provider or purchaser.
7. Funds will be sent to you within three (3) business days 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 designated.
WELCOME FUNDS INC and your referring advisor/broker,
if any, has no access to or control over viatical/life settlement
provider funds that are set aside in escrow or trust.
8. Entering into a viatical/life settlement contract 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;
and 2) reduce the insured’s ability to obtain additional life
insurance coverage in the future.
9. Total compensation payable to WELCOME FUNDS INC and
your referring advisor/broker, if any, shall collectively not
exceed a maximum of 8% of the Net Death Benefit (NDB) of
your policy. Proceeds of your settlement are represented by the
Net Purchase Price (NPP) as follows: NPP = Gross Purchase
Price (GPP) as paid by the viatical/life settlement provider
reduced by the total compensation as described above.
10. All medical, financial or personal information solicited or
obtained by a viatical/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 viatical/life
settlement between you and the viatical/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.
11. The insured may be contacted by the viatical/life settlement
provider or WELCOME FUNDS INC or either of its authorized
representatives for the purpose of determining the insured’s
health status. 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.
12. Any person who knowingly presents false information in an
application for a viatical/life settlement contract is guilty of a
crime and may be subject to penalty, including but not limited to
fines and confinement in prison.
13. WELCOME FUNDS INC recommends that you read the
viatical/life settlement contract and seek assistance from a
professional financial advisor and/or consult with your legal
advisor prior to signing it.
14. I/we confirm and acknowledge that WELCOME FUNDS INC
has provided me/us with a brochure developed and approved by
the Kansas Insurance Department describing the process of
viatical/life settlements.
I/We acknowledge that I/we have read and understand the disclosures above (1-14).
___________________________________________ _________________________________ ________
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.INSAUTH.EF1/16 © 2016 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 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 understand 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.HIPAA1.EF1/16 © 2016 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.HIPAA2.EF1/16 © 2016 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)
Consumer Alert
♦ If you are in good health and
someone asks you to sell your life
insurance policy, proceed with
caution. You may be a target for
fraud. Contact the Kansas Insur-
ance Department for more infor-
mation.
♦ If you have been contacted by
someone who wants you to buy a
policy and then sell it immedi-
ately, you should contact the Kan-
sas Insurance Department. You
may be a target for fraud.
♦ If you are asked to invest in a viat-
ical settlement, we recommend
you contact either the Kansas In-
surance Department or the Kansas
Securities Commission (785-296-
3307) to learn more about the is-
sues and risks that might be in-
volved in such an investment.
Consumer Assistance
1-800-432-2484
Kansas insurance Department
Sandy Praeger, Commissioner
1-800-432-2484
420 S.W. 9th St.
Topeka, KS 66612-1678
785-296-3071
E-mail: commissioner@ksinsurance.org
Homepage: www.ksinsurance.org
This publication was issued as a
public service by the
Kansas Insurance Department
Sandy Praeger, Commissioner
Selling
Your
Life Policy
What to
Know About
Viatical Settlements
Before you sell
Your Policy
Today it is possible for you to sell your
life insurance policy to someone else and
receive an immediate cash benefit to use for
whatever reason you choose. This financial
arrangement, known as a viatical settle-
ment, is best suited for people who are living
with immediate life-threatening illness and
facing difficult financial choices.
It may not always be in your best interest
to sell your policy. Before you take action,
you want to be sure you understand
♦ What future benefits you may lose
♦ What other options may be available
This brochure is designed to provide some
of that information. However, it only pro-
vides a starting point. If you have addi-
tional questions, please call us.
The Kansas Insurance Department
Consumer Assistance Division
1-800-432-2484
Make an informed decision
Have your needs changed?
♦ Before you sell your policy for cash you
should carefully consider the loss of valuable
insurance protection which you may not be
able to get again. Remember that the costs for
coverage increase significantly as you age and
that you also must be in good health to qual-
ify for coverage.
Check all of your options
♦ Find out if you have any cash value in your
policy. You may be able to (1) borrow from
the cash value, (2) cancel the policy for its cur-
rent cash value, (3) use the cash value as col-
lateral to secure a loan from a financial institu-
tion.
♦ Find out if you have an “accelerated benefit”
rider on your policy. If available, it could pay
you a substantial portion of your policy’s
death benefit without requiring you to sell
your policy. It may be your best option.
Other considerations
♦ Check out the tax implications. Not all pro-
ceeds from a viatical settlement are tax free.
♦ Find out if the proceeds would be subject to
the claims of any creditors.
♦ Find out if you will lose any public assistance
benefits such as food stamps, unem-
ployement, or Medicaid if you accept a cash
settlement for your life policy.
Consumer protections in Kansas
♦ Any agent or company arranging viatical set-
tlements must be licensed with the Kansas In-
surance Department.
♦ The company buying your policy must keep
your identity and medical history confidential
unless you give them written consent.
♦ To protect your proceeds, the company buying
your policy must put your money into an es-
crow account with an independent party dur-
ing the transfer process.
♦ You have the right to change your mind about
the settlement AFTER you receive the money,
provided you return all the money. You have
15 days to review your settlement arrange-
ment.
♦ The new owner of your policy is limited to the
number of times they may contact you about
your current health status.
♦ This is a summary of Kansas law. For more
detailed information refer to Kansas Statute
1999 Supp.40-2, 140 eta.seq. or consult with
your personal advisor.
A viatical settlement is a complex financial arrangement which may require
professional guidance. We suggest you find your own personal advisor
such as an accountant or tax attorney who will represent your interests.
Selling Your
Life Insurance
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Life Settlement Application Form - For Kansas Residents (Welcome Funds)

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Completed 26 June 2021

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