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

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Life Settlement Application Form - For Ohio 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 Ohio
Viatical Settlement Broker License
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
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 National
Association of Insurance Commissioners 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.EF5/08 © 2008 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
viatical/
life
settlement contra
ct
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.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 CONSIDERI
NG 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 r
eplacement policy
Interested in learning market value of policy Cash liquidity preferred due to current
financial situation
Other or provide further details: __________________________________________________________________________________
All
Policy Owner(s) and Insured(s) please sign at the bottom of the page, regardless of whether you complete all of the financial
information below.
Please be advised that any Policy Owner(s) and/or Insured(s) who declin
es 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 rele
ase 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.OHDISC.EF9/08 © 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
Fraud Warning: Any person who knowingly presents false information in an application for insurance
or viatical/life settlement contract is guilty of a crime and may be subject to fines and confinement in prison.
1. WELCOME FUNDS INC and your referring advisor/broker, if
any, represents exclusively you and not the insurer or provider or
any other person and owes you a fiduciary duty, including 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 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. Receipt of the proceeds of the viatical/life settlement may
adversely affect your eligibility for Medicaid or other
government benefits or entitlements. Advice should be obtained
from the appropriate government agencies.
4. Viatical/life settlement proceeds could be subject to the claims of
creditors.
5. There are possible alternatives to viatical/life settlement
contracts. 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. You have the right to rescind the viatical/life settlement contract
for at least fifteen (15) calendar days after you receive the
viatical/life settlement proceeds, as provided in section 3916.08
of the Ohio Revised code (Ohio Law). If the insured dies during
the rescission period, then the viatical/life settlement contract
shall be deemed rescinded, subject to repayment of all
viatical/life settlement proceeds to the viatical settlement
company.
7. Funds will be sent to you within three (3) business days after the
viatical/life settlement provider has received written
acknowledgement from the insurer or group administrator that
ownership of the policy or interest in the certificate has been
transferred and that the beneficiary has been designated pursuant
to the viatical/life settlement contract. 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 to be
forfeited; and 2) reduce the insured’s ability to obtain additional life
insurance coverage in the future. Assistance should be sought from a
financial advisor.
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. Actual compensation shall be
disclosed no later than the date of execution of the viatical/life
settlement contract.
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. Following the execution of the viatical/life settlement contract, the
viatical/life settlement provider or its authorized representative may
contact the insured for the purpose of determining the insured’s
health status and to confirm the insured’s residential or business
address and telephone number or for other purposes permitted by
law. Any such contact shall be limited to once in any three (3) month
period if the insured has a life expectancy of more than one (1) year
or to once per month if the insured has a life expectancy of one (1)
year or less.
12. 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.
13. 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 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
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
Selling Your
Life
Insurance
Policy
Understanding
Viatical
Settlements
What is a Viatical
Settlement?
A viatical settlement is the sale of a life
insurance policy to a third party. The owner
(viator) of the life insurance policy sells the
policy for an immediate cash benefit.
The buyer (the viatical settle
ment provider)
becom
e
s the
new owner of the life insurance
policy, pays future premiums, and collects the
death benefit when the insured dies.
At one ti
me, most viatical settlements were
from p
eople with a life-threatening illness.
Now, individuals who are not facing a health
crisis may sell their life insurance policies to
get cash.
Your state insurance department and
the National Association of Insurance
Commissioners want you to have the
facts before you sell your life
insurance policy. This brochure
provides some of that information, but
it is only a starting point. Consult your
own professional financial advisor,
attorney, or accountant to help you
decide if this is the most suitable
arrangement for you.
Consider Your Options
If you’re selling your policy to get cash
to pay expenses, check all of your
options. You may find a way to get more
cash from your life insurance policy.
1.
Ask your insurance agent or
com
p
any
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. You may also be
able to use the cash value as security
for a loan from a financial
institution.
2. Find out if your life insurance
policy has an accelerated death
benefit. An accelerated death
benefit typically pays some of the
policy’s death benefit before the
insured dies. It may be a way for
you to get cash from a policy
without selling it to a third party.
State Insuran
Department
ce
Consumer tips
• Comparison shop. Get quotes from several
companies to make sure you have a
co
mpetitive of
fer.
• Find
out the tax implications. No
t all
proceeds received
from the sale of your life
insurance po
licy are tax free.
• It’
s important to know that any of you
r
creditors cou
ld claim your cash settlement.
•
Find
out if you will lose any pub
lic
assistance benefits such as
food stamps or
M
edicaid if you get a cash settlement
.
• The bu
yer of your policy can periodically
ask you
about your health status. The buyer
is requ
ired to give you a privacy no
tice
o
utlining who will get this personal
information. Be sure to read it
.
•
Check all application forms for acc
uracy,
especially your medical history. All
questions must be answered truthfully and
comp
letely.
•
Make
sure the viatical settlement provide
r
agrees to
put your settlement proceeds into
an independent escrow account to protect
your funds during the transfer
.
Fin
d out if you have the right to change
your mind
about the settlement AFTER
you get the money. If so, how many days
do you have to reconsider and return the
money?
Questions to Ask
• Do I still need life insurance protection?
• If I sel
l my policy, how do they decide how
mu
ch cash I get?
• Is
this an employer or other group policy? If so
,
do I
need permission to sell it?
• If I sell m
y policy, who will be the legal
owne
r?
• Do I need t
he advice of a tax or estate planning
advisor before I decide to sell my policy?
• Who
will have specific information about
me,
my fa
mily or my health status?
• After I sell my policy, can it be resold by the
buy
er?
Your state insurance department may
have a list of viatical settlement
providers and brokers that are licensed
to do business in the state. Contact them
to make sure yours are on the list.
Always Check with
Your St
ate
• Contact your state insurance or securities
depa
rtments to learn about the issues and
risks of viatical settlements if:
• you’re considering selling your life
insuran
ce po
licy;
•
you’re asked to sell your life insurance
po
licy and your health hasn’t changed
since you bought the po
licy;
• yo
u’re asked to buy a new life insurance
policy and immediately sell it for cas
h.
Buying a Life
Insurance Policy?
If you’re interested in buying a life
insurance policy as an investment, contact
your state insurance department before you
make a decision.
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Life Settlement Application Form - For Ohio Residents (Welcome Funds)

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Completed 26 June 2021

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