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

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Life Settlement Application Form - For Kentucky 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 Kentucky
Life Settlement Broker License
FORM WFI.WELCOME.EF1/17 © 2017 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
Dear P
olicy 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 Consumer Guide to Understanding Life Settlements
issued by the Kentucky Department of Insurance 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,
John M. W
elcom
Founder & CEO
FORM WFI.EF7/10 © 2010 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
Fraud Warning: Any person who knowingly presents false information in an application for insurance
or a life settlement contract is guilty of a crime & may be subject to fines & confinement in prison
.
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.EF7/10 © 2010 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.
FORM WFI.EF7/10 © 2010 Welcome Funds Inc
- 3 -
ADDITIONAL INFORMATION
I. PLEA
SE DESCRIBE REASONS FOR CONSIDERING THE SALE OF POLICY(IES), CHECK ALL THAT APPLY:
No
longer require or want to pay for the life coverage Planning to lapse, cancel, or surrender the policy
Health
& living expenses are a financial burden Considering a 1035 Exchange or replacement policy
In
terested in learning market value of policy Cash liquidity preferred due to current financial situation
O
ther 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
and insurance information below.
If the information below is not completed, then the policy owner(s) and insured(s) acknowledge that Welcome Funds Inc may not be ab
le
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. FINANCIAL PROFILE
(PLEASE USE COMBINED FIGURES FOR JOINT ACCOUNTS):
INVESTME
NT OBJECTIVES
: Capital Preservation Income Capital Appreciation/Growth Speculation
(check all that apply)
POLICY OWN
ER’S TAX BRACKET
: [10%] [15%] [25%] [28%] [33%] [35%] Other
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
III. LIFE INSURANCE
TOTAL
AMOUNT OF IN-FORCE LIFE INSURANCE COVERING INSURED(S): $_____________________________________
____
__________________________________________________
Verified and Confirmed By:
___________________________________________ _________________________________ ________
Signature of Primary Insured Printed Name Date
___________________________________________ _________________________________ ________
Signature of Secondary Insured (if applicable) Printed Name Date
___________________________________________ _________________________________ ________
Signature of Policy Owner #1 (if not Insured) Printed Name Date
___________________________________________ _________________________________ ________
Signature of Policy Owner #2 (if not Insured) Printed Name Date
FORM WFI.EF7/10 © 2010 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 re
presentatives to release and/or transmit
electronically all financial and insurance information gathered from this Evaluation Request for Sale of Existing Life Insurance,
including but not limited to medical records, notes and lab reports pertaining to the insured’s health, to the appropriate parties who
have an identifiable need to facilitate the sale of my/our life insurance policy.
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.KYDISC.EF3/12 © 2012 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 (PAGE 1 OF 2)
Fraud Warning: Any person who knowingly presents false information in an application for insurance
or a life settlement contract is guilty of a crime & may be subject to fines & confinement in prison.
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________----_
1. There ar
e pos
sible alternati
v
es to life
settlement contracts including but not limited to accelerated benefits or policy
loans
offered
under your policy.
2. Some or all of the proceeds of the life settlement may be taxable under federal income tax laws and state franchise
and
income tax laws. WELCOME FUNDS INC is not
a tax advisor and assistance should be sought from a personal
tax
advisor.
3. Proceeds of the life settlement contract could be subject to the claims of creditors.
4. Receipt of proceeds of a life settlement contract may adversely affect the owner’s eligibility for Medicaid or other
government benefits or entitlements. Advice should be obtained from the appropriate government agencies.
5. Life settlement proceeds could
be s
ubject to the claims of creditors.
6. The owner has a right to cancel a life settlem
ent contract before the earlier of 30 calendar days of the date it is executed by
all parties or 15 calendar days after receipt of the proceeds of the life settlement
contract by the owner.
7. Entering into a life settlement contract may cause other rights or benefits, including conversion rights and waiver of
premium benefits that may exist under the policy, to be forfeited by the owner. Assistance should be sought from a
financial advisor.
8. Funds will be sent to the owner within three (3) business days after the life settlement provider has received the insurer’s
or grou
p administrator’s acknowledgment that ownership of the policy has been transferred and the beneficiary has been
designated pursuant to the life settlement contract. WELCOME FUNDS INC has no access to or control
over life
settlement provider funds that are set asi
d
e in escrow or trust.
9. Total life settlem
ent broker compensation shall be disclosed no later than the date the life settlement cont
ract is signed
by all parties.
10. 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 between you and the life settlement provider. If you are asked
to provide t
his 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 permissi
on to share
inform
ation every two (2) years. In addition, information regarding your and the insured’s identity and insured’s medica
l
condition will 1) be shared with the in
surer that issued the life insurance policy; and 2) shall be available to each
subsequent owner of the life insurance policy.
[Additional Disclosures on Next Page]
FORM WFI.KYDISC.EF3/12 © 2012 Welcome Funds Inc
NOTICE OF DISCLOSURE (PAGE 2 OF 2)
11. The insured may
be contacted by the life settlement provider 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 (1) year, and no more
than once per month if the insured has a life expectancy of one (1) year or less.
12. WELCOME FUNDS INC reco
mmends that the owner read the life settlement contract and seek assistance from
a
professional financial advisor and/or consult with a legal advisor prior to signing it.
13. I/we confirm and acknowledge that WELCOME F
UNDS INC has provided me/us with the most recent brochure
developed by the Kentucky Department of Insurance titled, “Kentucky Consumer Guide to Understanding Life
Settlements.
I/We acknowledge that I/we have read and understand the disclosures above (1-13).
___________________________________________ _________________________________ ________
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
FORM WFI.INSAUTH.EF3/10 © 2010 Welcome Funds Inc
WELCOME FUNDS INC.
4755 TECHNOLOGY WAY
SUITE 202
BOCA RATON, FL 33431
TOLL-FREE: 877.227.4484
PHONE: 561.862.0244
FAX: 561.862.0242
WWW.WELCOMEFUNDS.COM
AUTHORIZATION FOR THE RELEASE OF LIFE INSURANCE POLICY INFORMATION
_________________________________________ __________________________________________
Life Insurance Company Policy Number
_________________________________________ __________________________________________
Printed Name of All Policy Owner(s) Printed Name of Insured(s)
By signing this release, I/we authorize the life insurance company named above and any other company or person that has
information related to the life insurance policy named above to:
a) release such information to WELCOME FUNDS INC and its authorized representatives; and
b) reply
immediately to any request for information or documents required by WELCOME FUNDS INC relating to the life
insurance policy named above.
The information to
be released includes but is not limited to the fol
lowing:
a) original copy of
the policy; b) applications for insurance; c) riders; d) current and projected illustrations; e) conversions; f)
withdrawals;
g) lapse or reinstatement coverage; h) verification of coverage; i) change in ownership and beneficiary; j)
assignments; k) premium payments and payment provisions; l) contestable and suicide status; and m) any and all other
information.
In addition, I/we authorize:
a) WELCOME FUNDS INC to share the information it receives with any other company
or person for the purpose of
evaluating all of my options related to the policy named above;
b) that this Authorization shall remain valid until (i) I/we withdraw our consent, pursuant to applicable law; or (ii) the death of
the Insured (or if m
u
ltiple Insureds, until the death of the last to survive), unless any
applicable state statute or regulation
requires a different time period. If a different time period is required, this Authorization shall remain valid for the maximum
period allowed per state statute or regulation;
c) that a photocopy, PDF or electronic file or fax of this Authorization is as valid as an original.
Furthermore, I/we certify:
a) that this Authorization is being executed and delivered freely as of the date written below; and
b)
understand the contents of this Author
ization in full.
WELCOME FUNDS IN
C
Authorized 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.HIPAA1.EF3/10 © 2010 Welcome Funds Inc.
WELCOME FUNDS INC.
4755 TECHNOLOGY WAY
SUITE 202
BOCA RATON, FL 33431
TOLL-FREE: 877.227.4484
PHONE: 561.862.0244
FAX: 561.862.0242
WWW.WELCOMEFUNDS.COM
AUTHORIZATION FOR THE DISCLOSURE OF PROTECTED HEALTH INFORMATION
PRIMARY INSURED (“Release”)
I, _______________________________________ (Insured), _______________ (Date of Birth) __________________________ (SS #)
authorize the disclosure to Welcome Funds Inc. (“WFI”) of my protected health information as defined under the privacy regulations for
all purposes of the Federal Health Insurance Portability and Accountability Act of 1996 (“1996 ACT”) also known as HIPAA. I
understand that my health information under this Release 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.
I. The term, “WFI” shall include but not be limited to the following with respect to WFI under this Release
.
A. Its successors or assigns. B. Its agents and/or affiliates. C. Its officers. D. Its employees. E. Its subsidiaries and corporate parents.
F. Its independent contractors or consultants. G. Its third party life expectancy and service providers. H. Its providers or financing
sources (and any third party in connection with such financing). I. Other WFI authorized entities or authorized representatives and/or
their agents. J. Other persons or entities needing to receive, evaluate, underwrite or solicit bids for a sale of any life insurance policy.
II. Authorized parties who may release my medical records include the following (collectively, the “Directed Persons”).
A. Insurance co
mpanies. B. Medical Information Bureau. C. Any other institution or person with my medical records or information,
including the following. 1. Physicians. 2. Doctors. 3. Physicians practice groups. 4. Nurses. 5. Pharmacies. 6. Clinics. 7. Med
ical
centers. 8. Hospitals. 9. Any other health care provider. I acknowledge that Directed Persons shall be guided by instructions provided
by WFI, as the request using this Release is as valid as if I had requested my own medical records.
III. Medical rec
ords consist of all records concerning my past, present or future physical or mental history or condi
tion as to
diagnosis, treatment and/or prognosis (“Medical Records”). Medical Records include but are not limited to the following.
A. X-rays. B.
Charts. C. Medical Files/Records. D. Hospital records. E. Laboratory tests and results. F. Test and examination reports.
G. Problem lists. H. Information relating to the following. a. Sexually transmitted diseases. b. Psychiatric evaluations, treatment
and/or information. I. And any and all of my health and medical data and information and records. This Release shall also serve as
my written consent to disclosure of drug, alcohol or HIV related information and medical records. Medical Records include but a
re
not
limited to private, privileged, protected or personal health information defined as “Protected Health Information” under th
is
Release and the 1996 ACT whether or not personally or individually identifiable or protected under any federal or state
confidentiality or privacy laws or regulations.
IV. Authorized recipients of information from WFI under this Release may include the following but will not be limited to and
can be used for the purpose listed below.
A. medical underwriters
. B. lenders. C. financing entities. D. brokers/brokerages. E. buyers of life insurance policies. F. life
expectancy providers. G. stop-loss re-insurers. Each will include their. 1. affiliates. 2. agents. 3. subsidiaries. 4. corporate parents. 5.
independent contractors. 6. consultants. 7. service providers. 8. authorized representatives. 9. officers. 10. directors. 11. employees.
Each an (“Authorized Recipient”). This Release and all disclosures of my Medical Records made under this Release are for purposes
of allowing the Authorized
Recipient to. a. analyze. b. assess. c. evaluate or underwrite my health/medical condition or
life
expectancy. In connection with the possible sale of any life insurance policy, or certificate of life insurance, under which my life is
insured. As a result of this Release, my ongoing health status may be tracked by WFI or Authorized Recipient.
V. Expiration of Release, right to remove Release, and additional items.
This Release sh
all be valid until the Insured’s death or the maximum time allowed by state or federal law. I understand that I may
remove this Release at any time by notifying any Directed Persons in writing of my removal and by delivering the removal document
by mail or personal delivery to any Directed Persons. I also understand that if Directed Persons have already released Medical
Records that any removal of Release shall not cover that situation. This Release is not a consent or authorization requested by a
health care provider, health care clearinghouse or health plan covered by the privacy regulations promulgated pursuant to the 1996
Act. As a result of this Release, either of the following may occur with respect to Medical Records disclosed by the Directed Persons
or other covered entity (as defined under the 1996 Act) to WFI. a. They may be redisclosed. b.They may no longer be protected by
privacy laws provided by law, including but not limited to the 1996 Act.
I certify that I am executing this Release freely and unilaterally as of the date written below. This Release is written in plain
language. I fully understand the contents of this Release. I had the opportunity to consult with an attorney prior to signing this
Release. I agree that all Directed Persons can rely upon a fax or copy or other reproduction of this Release.
____________________________________________________________________________________________
List of Directed Persons (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 Authori
ty (if any). ___________________________________________________________________________________
(POA, Guardian ad Litem or similar status – Please attach legal documents for verification)
FORM WFI.HIPAA2.EF3/10 © 2010 Welcome Funds Inc.
WELCOME FUNDS INC.
4755 TECHNOLOGY WAY
SUITE 202
BOCA RATON, FL 33431
TOLL-FREE: 877.227.4484
PHONE: 561.862.0244
FAX: 561.862.0242
WWW.WELCOMEFUNDS.COM
AUTHORIZATION FOR THE DISCLOSURE OF PROTECTED HEALTH INFORMATION
SECONDARY INSURED (“Release”)
I, _______________________________________ (Insured), _______________ (Date of Birth) __________________________ (SS #)
authorize the disclosure to Welcome Funds Inc. (“WFI”) of my protected health information as defined under the privacy regulations for
all purposes of the Federal Health Insurance Portability and Accountability Act of 1996 (“1996 ACT”) also known as HIPAA. I
understand that my health information under this Release 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.
I. The term, “WFI” shall include but not be limited to the following with respect to WFI under this Release
.
A. Its successors or assigns. B. Its agents and/or affiliates. C. Its officers. D. Its employees. E. Its subsidiaries and corporate parents.
F. Its independent contractors or consultants. G. Its third party life expectancy and service providers. H. Its providers or financing
sources (and any third party in connection with such financing). I. Other WFI authorized entities or authorized representatives and/or
their agents. J. Other persons or entities needing to receive, evaluate, underwrite or solicit bids for a sale of any life insurance policy.
II. Authorized parties who may release my medical records include the following (collectively, the “Directed Persons”).
A. Insurance com
panies. B. Medical Information Bureau. C. Any other institution or person with my medical records or information,
including the following. 1. Physicians. 2. Doctors. 3. Physicians practice groups. 4. Nurses. 5. Pharmacies. 6. Clinics. 7. Med
ical
centers. 8. Hospitals. 9. Any other health care provider. I acknowledge that Directed Persons shall be guided by instructions provided
by WFI, as the request using this Release is as valid as if I had requested my own medical records.
III. Medical rec
ords consist of all records concerning my past, present or future physical or mental history or condi
tion as to
diagnosis, treatment and/or prognosis (“Medical Records”). Medical Records include but are not limited to the following.
A. X-rays. B.
Charts. C. Medical Files/Records. D. Hospital records. E. Laboratory tests and results. F. Test and examination reports.
G. Problem lists. H. Information relating to the following. a. Sexually transmitted diseases. b. Psychiatric evaluations, treatment
and/or information. I. And any and all of my health and medical data and information and records. This Release shall also serve as
my written consent to disclosure of drug, alcohol or HIV related information and medical records. Medical Records include but a
re
not
limited to private, privileged, protected or personal health information defined as “Protected Health Information” under th
is
Release and the 1996 ACT whether or not personally or individually identifiable or protected under any federal or state
confidentiality or privacy laws or regulations.
IV. Authorized recipients of information from WFI under this Release may include the following but will not be limited to and
can be used for the purpose listed below.
A. medical underwriters. B. lenders
. C. financing entities. D. brokers/brokerages. E. buyers of life insurance policies. F. life
expectancy providers. G. stop-loss re-insurers. Each will include their. 1. affiliates. 2. agents. 3. subsidiaries. 4. corporate parents. 5.
independent contractors. 6. consultants. 7. service providers. 8. authorized representatives. 9. officers. 10. directors. 11. employees.
Each an (“Authorized Recipient”). This Release and all disclosures of my Medical Records made under this Release are for purposes
of allowing the Authorized
Recipient to. a. analyze. b. assess. c. evaluate or underwrite my health/medical condition or
life
expectancy. In connection with the possible sale of any life insurance policy, or certificate of life insurance, under which my life is
insured. As a result of this Release, my ongoing health status may be tracked by WFI or Authorized Recipient.
V. Expiration of Release, right to remove Release, and additional items.
This Release sh
all be valid until the Insured’s death or the maximum time allowed by state or federal law. I understand that I may
remove this Release at any time by notifying any Directed Persons in writing of my removal and by delivering the removal document
by mail or personal delivery to any Directed Persons. I also understand that if Directed Persons have already released Medical
Records that any removal of Release shall not cover that situation. This Release is not a consent or authorization requested by a
health care provider, health care clearinghouse or health plan covered by the privacy regulations promulgated pursuant to the 1996
Act. As a result of this Release, either of the following may occur with respect to Medical Records disclosed by the Directed Persons
or other covered entity (as defined under the 1996 Act) to WFI. a. They may be redisclosed. b.They may no longer be protected by
privacy laws provided by law, including but not limited to the 1996 Act.
I certify that I am executing this Release freely and unilaterally as of the date written below. This Release is written in plain
language. I fully understand the contents of this Release. I had the opportunity to consult with an attorney prior to signing this
Release. I agree that all Directed Persons can rely upon a fax or copy or other reproduction of this Release.
____________________________________________________________________________________________
List of Directed Persons (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.NONXBROKERAUTH.EF3/10 © 2010 Welcome Funds Inc
WELCOME FUNDS INC.
4755 TECHNOLOGY WAY
SUITE 202
BOCA RATON, FL 33431
TOLL-FREE: 877.227.4484
PHONE: 561.862.0244
FAX: 561.862.0242
WWW.WELCOMEFUNDS.COM
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 represents the best interests of consumers in an effort to obtain one or more offers for the sale of their
policy(ies). As your designated broker, WELCOME FUNDS INC incurs the necessary, required and related costs to facilitate a life
settlement while providing the following services, including but not limited to:
• Qualification analysis and review
• Evaluatio
n Form assessment
• Submission to one or more life settlement providers
• Medical underwriting & insurance verifications
• Closing services including contract review & assistance
with requirements of life settlement providers
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 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
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, ge
nerate and secure conditional and appropriate offers as determined by WELCOME FUNDS INC, pursuant to its
typical practices, for the sale of my/our life insurance policy(ies) as stated above.
2. Reco
gnizing the proprietary nature of such offers as evaluated, underwritten, solicited, generated and secured by
WELCOME
FUNDS INC for the period of time as described above and pursuant to this Agreement.
3. A
greeing to the total compensation, as described in this paragraph, payable to WELCOME FUNDS INC and your referring
advisor/broker, if any. Such
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
KentucKy
consumer Guide
to understandinG
Life settLements
Commonwealth of Kentucky
Public Protection Cabinet
Defining the Terms
A life settlement (which includes viatical settlements) occurs when a person sells his or her life in-
surance policy to a third party. The owner of the insurance policy sells the policy for a cash payment
that is less than the full amount of the death benefit.
A life settlement provider is the person or company who buys the life insurance policy. The life
settlement provider becomes the new owner and has control over the policy including naming a ben-
eficiary.
The life settlement contract is the agreement in which the life settlement provider agrees to pur-
chase all or a portion of the life insurance policy and the owner agrees to sell all or a portion of the
life insurance policy.
The life settlement broker can assist an owner of a life insurance policy in searching for the right
life settlement provider to purchase the policy. The life settlement broker then will receive a commis-
sion for helping with the sale. The life settlement broker has a legal obligation to find the best deal for
the owner of the life insurance policy.
The person selling the life insurance policy is the owner of the life insurance policy. The owner will
receive a settlement payment for the sale of the policy, which will be an amount that is less than the
face amount of the life insurance policy.
Understanding Life Settlements
A viatical settlement is the sale of a life insurance policy to a third party. The owner of the life in-
surance policy sells it for a payment that is less than the full amount of the death benefit. The buyer
becomes the new owner and has the right to make any changes to the life insurance policy including
naming the beneficiary.
People decide to sell their life insurance policies for many reasons. Some of those
reasons may be changing needs of dependents, wanting to reduce insurance pre-
miums or needing to raise cash for expenses. People with a terminal or chronic
illness may want to sell their policy in order to pay medical bills. Before making
the decision to sell a life insurance policy, always check for alternatives. There
may be an option in the life insurance policy to accelerate death benefits.
A life settlement may or may not be the right choice for you. The Kentucky Department of Insurance,
along with the National Association of Insurance Commissioners (NAIC), is concerned that many
consumers may not fully understand life settlements. In addition, some or all of the proceeds of a life
settlement may be taxable, and receipt of life settlement proceeds may affect your eligibility for Med-
icaid or other government benefits. Please be sure to check with a financial professional before making
any decision.
Be sure you fully
understand life
settlements before
you make any
decisions.
Consumer Tips
Understand how the process works and read all documents care-
fully.
Decide whether to sell your policy directly to a life settlement pro-
vider or go through a life settlement broker who will do the com-
parison shopping for you.
If you do not use a life settlement broker, comparison shop on your
own.
You do not have to accept any life settlement offer.
Be sure to read through the life settlement application for accuracy,
especially information about your medical history.
Understand that you have the ability to cancel the contract within
the first 30 days after you have signed a contract or 15 days after
you have received the settlement money.
Understand that buyers will have access to your medical informa-
tion and they have the right to contact you as often as every 3
months to discuss any changes in your medical information.
Additional Questions to Consider
Do I still need life insurance protection?
How does the life settlement provider decide how much cash my policy is worth?
Do different life settlement providers make different offers?
What costs including commissions will I have to pay if I sell my policy?
Are the life settlement provider and/or broker licensed in Kentucky?
Who will become the legal owner of the policy if I sell it?
How often will I be contacted to determine my continuing health condition?
After I sell my policy, can it be resold?
Will I always know who owns the policy?
Steps in the Life Settlement Process
A written statement from a licensed attending physician that you are of sound mind to sell your
policy.
Sign a contract in which you:
consent to the life settlement contract
verify any catastrophic or life threatening illness was diagnosed after the policy was issued
confirm that you fully understand the life settlement contract
release your medical records
acknowledge that you entered into the life settlement contract freely and voluntarily
1.
2.
a.
b.
c.
d.
e.
Consumer Alert
Be cautious if you are:
asked to invest in or
buy a life settlement
contract;
interested in selling
your life insurance
policy and want more
information; or
contacted by someone
who wants you to buy
a life insurance policy
then immediately sell
that policy as a life
settlement transaction.
*
*
*
Explore All Your Options: A Checklist
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, such as
accelerated benefits. It could pay you a substantial portion of your policy’s death benefit without
selling your policy to a third party. Also ask if there is any cash value in your 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. You also may be able to use the cash value as security for a loan from a financial
institution.
Contact a licensed life settlement broker or licensed life settlement provider for information about
life settlements.
Consult with your own financial adviser who knows your personal financial needs. Be sure to ask
about tax and other financial consequences if you sell your policy. Contact a professional tax ad-
viser to find out the tax implications. Proceeds are only tax-free under certain circumstances.
Contact the Kentucky Department of Insurance at 800-595-6053 for information about current
laws that may protect you.
Other Things to Consider
Know that your creditors could claim the proceeds.
Find out if you will lose any Medicaid benefits.
Find out if you will lose any public assistance benefits.
Know that you must provide certain medical and personal information to third parties who will
receive 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.
Kentucky Public Protection Cabinet
Department of Insurance
P.O. Box 517, Frankfort, KY 40602-0517
Toll free: 800-595-6053 TDD: 800-648-6056
http://insurance.ky.gov/
The Kentucky Department of Insurance does not discriminate on the basis of race, color, religion, sex, national ori-
gin, sexual orientation or gender identity, ancestry, age, disability or veteran status. The cabinet provides, on request,
reasonable accommodations necessary to afford an individual with a disability an equal opportunity to participate in
all services, programs and activities. To request materials in an alternate format, contact the Department of Insur-
ance, Communications Office, P.O. Box 517, Frankfort, KY 40602-0517, toll-free 800-595-6053. Hearing and speech-
impaired persons can contact an agency by using the Kentucky Relay Service, a toll-free telecommunication service.
For Voice to TDD call 800-648-6057. For TDD to Voice, call 800-648-6056.
Printed with state
funds on recycled
paper
August 2008
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Life Settlement Application Form - For Kentucky Residents (Welcome Funds)

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Completed 26 June 2021

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