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

Fill Online, Printable, Fillable, Blank Life Settlement Application Form - For Oklahoma Residents (Welcome Funds) Form

Use Fill to complete blank online WELCOME FUNDS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

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

On average this form takes 44 minutes to complete

The Life Settlement Application Form - For Oklahoma Residents (Welcome Funds) form is 17 pages long and contains:

  • 0 signatures
  • 78 check-boxes
  • 138 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Welcome Funds forms online.

BROWSE WELCOME FUNDS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
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 Oklahoma
Viatical Settlement Broker License
FORM WFI.OK.EF11/08 © 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
LETTER FROM THE PRESIDENT
Dear Policy Owner/Insured:
Thank you for choosing WELCOME FUNDS INC to help you determine and identify the merits and value of
selling your policy. We understand that the process can be intimidating and overwhelming and it is our job to
not only maximize the sales value of your policy(ies) in the secondary market, but also to provide a seamless,
transparent and fully informed experience. Please complete our Evaluation Request for Sale of Existing Life
Insurance and sign the appropriate pages.
As your designated broker who represents your best interests and follows your instructions, WELCOME
FUNDS INC incurs the necessary, required and related costs to facilitate the potential sale of your policy related
to the following services:
• Evaluation Form assessme
nt.
• Medical underwriting and insurance verifications.
• Obtaining and forwarding independent third party life expectancy reports.
• Submission to multiple authorized and/or registered buyers of life insurance policies.
• Best execution negotiation to maximize fair market value of the sale of your policy.
• Closing services including contract review and assistance with contingency requirements of buyers of
life insurance policies.
In addition, please r
ead the Notice of Disclosure and the Broker Authorization and Services Agreement carefully
and sign accordingly. These pages represent the first step in explaining your rights and obligations associated
with the process. Furthermore, we have attached a brief brochure issued by the National Association of
Insurance Commissioners (NAIC), a non-profit organization of insurance regulators from all 50 states, to
provide an unbiased, independent description of selling policies in the secondary market. Please read the NAIC
material as well.
Please be advised that the personal information acquired shall only be shared with individuals and entities with
an identifiable need to help determine the market value of your policy, including but not limited to life
expectancy underwriters and potential buyers of your policy. All parties involved in the analysis, evaluation,
underwriting and contingent pricing for transactions are required to maintain strict privacy and confidentiality
safeguards pursuant to applicable state and federal regulations.
Once again thank you for allowing us the opportunity to help you reach your financial goals and to represent
you in the secondary market for the potential sale of your life insurance policy.
Sincerely,
John M. Wel
c
o
m
President
FORM WFI.OK.EF11/08 © 2008 Welcome Funds Inc
- 4 -
WELCOME FUNDS INC.
4755 TECHNOLOGY WAY
SUITE 202
BOCA RATON, FL 33431
TOLL-FREE: 877.227.4484
PHONE: 561.862.0244
FAX: 561.862.0242
WWW.WELCOMEFUNDS.COM
EVALUATION REQUEST FOR SALE OF EXISTING LIFE INSURANCE
The information provided below shall be used to evaluate, underwrite and generate
conditional offers for the sale of your life insurance policy.
PRIMARY INSURED’S PERSONAL INFORMATION
PRIMARY INSURED NAME (AS LISTED WITH LIFE INSURANCE CARRIER) DATE OF BIRTH SOCIAL SECURITY NUMBER
CURRENT HOME ADDRESS TELEPHONE NUMBER
CITY STATE ZIP CODE
PRIMARY ATTENDING PHYSICIAN SPECIALTY CITY/STATE DATE LAST SEEN TELEPHONE NUMBER
OTHER PHYSICIANS SEEN IN LAST 5 YEARS SPECIALTY CITY/STATE DATE LAST SEEN TELEPHONE NUMBER
OTHER PHYSICIANS SEEN IN LAST 5 YEARS SPECIALTY CITY/STATE DATE LAST SEEN TELEPHONE NUMBER
HOSPITAL (S) NAME, ADDRESS, TELEPHONE NUMBER THAT HAS TREATED YOU IN THE LAST 24 MONTHS FOR YOUR ILLNESS
PLEASE PROVIDE A BRIEF DESCRIPTION OF YOUR MEDICAL HISTORY
SECONDARY INSURED’S PERSONAL INFORMATION (IF APPLICABLE – SURVIVORSHIP ONLY)
SECONDARY INSURED NAME (AS LISTED WITH LIFE INSURANCE CARRIER) DATE OF BIRTH SOCIAL SECURITY NUMBER
CURRENT HOME ADDRESS TELEPHONE NUMBER
CITY STATE ZIP CODE
PRIMARY ATTENDING PHYSICIAN SPECIALTY CITY/STATE DATE LAST SEEN TELEPHONE NUMBER
OTHER PHYSICIANS SEEN IN LAST 5 YEARS SPECIALTY CITY/STATE DATE LAST SEEN TELEPHONE NUMBER
OTHER PHYSICIANS SEEN IN LAST 5 YEARS SPECIALTY CITY/STATE DATE LAST SEEN TELEPHONE NUMBER
HOSPITAL (S) NAME, ADDRESS, TELEPHONE NUMBER THAT HAS TREATED YOU IN THE LAST 24 MONTHS FOR YOUR ILLNESS
PLEASE PROVIDE A BRIEF DESCRIPTION OF YOUR MEDICAL HISTORY
Family Member Spouse Business Partner Other:________________________
PLEASE CHECK APPICABLE RELATIONSHIP TO PRIMARY INSURED (IF APPLICABLE)
If there are additional physi
cians or if there is additional medical information,
then please attach a separate sheet with complete details.
FORM WFI.OK.EF11/08 © 2008 Welcome Funds Inc
- 5 -
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.OK.EF11/08 © 2008 Welcome Funds Inc
- 6 -
FINANCIAL INFORMATION (REQUIRED FOR SUITABILITY REVIEW)
All Policy Owner(s) and Insured(s) please sign at the bottom of the page, regardless of whether you complete all of the financial
information below.
Please be advised that any Policy Owner(s) and/or Insured(s) who declines to provide full and complete financial data acknowledges and
accepts responsibility that such lack of data will impede Welcome Funds Inc’s ability to provide recommendations it deems suitable,
based on personal and specific financial needs, conditions and situations.
Check here if you choose NOT to complete some or all of the requested financial information below (and sign below).
I. 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): $_____________________________________
II. PLEASE DESCRIBE REASONS FOR CONSIDERING THE SALE OF POLICY(IES), CHECK ALL THAT APPLY:
No longer require or want to pay for the life coverage Planning to lapse, cancel, or surrender the policy
Health & living expenses are a financial burden Considering a 1035 Exchange or replacement policy
Interested in learning market value of policy Cash liquidity preferred due to current financial situation
Other or provide further details: __________________________________________________________________________________
III. PLEASE CERTIFY THE CURRENT ACCREDITED INVESTOR STATUS OF THE POLICY OWNER:
THE POLICY OWNER IS CONSIDERED AN ACCREDITED INVESTOR: YES NO
(Refer to the definitions below to answer the above question and if “yes,” then please check the appropriate description)
________
INDIVIDUALS:
1. An individual that has a net worth or joint net worth, with the individual’s spouse, in excess of $1,000,000. “Net worth” for these
purposes is defined as the value of total assets at fair market value, including but not limited to home, home furnishings and
automobiles, less total liabilities; or
________
2. An individual that (i) had income (exclusive of any income attributable to the individual’s spouse) of more than $200,000 for
each of the past two years or joint income with the individual’s spouse in excess of $300,000 in each of those years, and (ii)
reasonably expects to reach the same individual income level, or the same joint income level, as the case may be, in the current
year; or
________
ENTITIES:
3. A corporation, partnership, limited liability company, Massachusetts or similar business trust or tax-exempt organization as
defined in Section 501(c)(3) of the Code, that (i) has total assets in excess of $5,000,000, and (ii) was not formed for the specific
purpose of investing in the life insurance policy and then selling it; or
________
4. A revocable trust which may be amended or revoked at any time by the grantors thereof, and of which all of the grantors are
accredited investors under either (1) or (2) above; or
________
5. A trust (i) that has total assets in excess of $5,000,000, (ii) that was not formed for the specific purpose of acquiring the life
insurance policy and then selling it, and (iii) whereby the investment decisions are directed by a person who has such knowledge
and experience in business and financial matters and who can evaluate the merits and risks of its investments; or
________
6. A trust for which a bank or savings and loan association is acting as fiduciary in directing investment decisions; or
________
7. An entity whose equity owners are each “accredited investors” i.e., persons meeting the requirements set forth in either of (1) or
(2) above.
Verified and Confirmed By:
___________________________________________ _________________________________ ________
Signature of Primary Insured Printed Name Date
___________________________________________ _________________________________ ________
Signature of Secondary Insured (if applicable) Printed Name Date
___________________________________________ _________________________________ ________
Signature of Policy Owner #1 (if not Insured) Printed Name Date
___________________________________________ _________________________________ ________
Signature of Policy Owner #2 (if not Insured) Printed Name Date
FORM WFI.OK.EF11/08 © 2008 Welcome Funds Inc
- 7 -
PERSONAL ACKNOWLEDGEMENTS
I. Do you have a referring advisor/broker authorized, on your behalf, to a) represent your interests regarding this Evaluation
Request & potential transaction; & b) to accept offers, if any, for the sale of your existing life insurance policy?
Yes No
If Yes, then please provide the name(s) of such advisor(s)/broker(s) below:
____________________________________________________ _____________________________________________________
Name of Referring Advisor /Broker #1 Name of Referring Advisor/Broker #2 (if applicable)
II. Have you signed a Power of Attorney (POA) granting a legal representative to act on your behalf or do you have a
Guardian ad Litem or similar legal representative acting on your behalf regarding this Evaluation Request & Potential
Transaction?
Primary Insured: Yes No Policy Owner #1: (if not Insured): Yes No
Secondary Insured (if applicable): Yes No Policy Owner #2 (if applicable): Yes No
If Yes, then please 1) attach the applicable legal documents to this Evaluation Request; 2) have the legal representative of
the insured sign the “Authorization for Disclosure of Protected Health Information” forms for the primary and secondary
insured as applicable; and 3) provide the names of such legal representative(s) below:
__________________________________________________ __________________________________________________
Name of Legal Representative of Primary Insured (if applicable) Name of Legal Representative of Policy Owner #1 (if applicable)
__________________________________________________ __________________________________________________
Name of Legal Representative of Secondary Insured (if applicable) Name of Legal Representative of Policy Owner #2 (if applicable)
III. How did you learn about the option to sell your insurance policy?
Through my/our own knowledge and/or research and asked to receive this Evaluation Request.
Through my/our referring advisor/broker.
IV. Was this insurance policy premium financed?
Yes No
If yes, then please 1) attach all finance documents, including contracts, trusts and/or corporate documents etc…in order to
evaluate and determine the validity and legality of this potential transaction for insurable interest; 2) provide the name of
the financing company: _____________________________________________________.
Name of Financing Company (if applicable)
I/We represent that the information contained in this Evaluation Request for Sale of Existing Life Insurance is correct and accurate
and acknowledge that WELCOME FUNDS INC may rely on such information, including but not limited to the Personal
Acknowledgements above. I/we will immediately notify WELCOME FUNDS INC of any changes.
I/We give my/our consent to WELCOME FUNDS INC, its agents and/or authorized representatives to release and/or 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.OK.EF11/08 © 2008 Welcome Funds Inc
- 8 -
WELCOME FUNDS INC.
4755 TECHNOLOGY WAY
SUITE 202
BOCA RATON, FL 33431
TOLL-FREE: 877.227.4484
PHONE: 561.862.0244
FAX: 561.862.0242
WWW.WELCOMEFUNDS.COM
NOTICE OF DISCLOSURE
1. WELCOME FUNDS INC and your referring advisor/broker, if
any, represents 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
W
ELCOME FUNDS INC and your referring advisor/broke
r, 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 insuran
ce.
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 a viatical/life settlement contract
before the earlier of thirty (30) calendar days after the date upon
which the settlement contract is executed by all parties or fifteen
(15) calendar days after the settlement proceeds have been paid
to you. Rescission, if exercised by you, is effective only if both
notice of the rescission is given, and you repay all proceeds and
any premiums, loans and loan interest paid on account of the
viatical/life settlement within the rescission
period. If the
insured dies during the rescission period, then the settlement
contract shall be deemed rescinded, subject to your or your
estate’s repayment of all settlement proceeds and any premiums,
loans and loan interest on the viatical/life settlement within sixty
(60) day
s of the insured’s death.
7. Funds will be sent to you within three (3) business days after the
viatical/life settlement provider has received the insurer or
group administrator’s written acknowledgment that ownership
of the policy or interest in the certificate has been transferred
and the be
neficiary has been designated. WELCOME FUND
S
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 a
ny, 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 the life settlement contract is signed by all parties.
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 execution of a viatical/life settlement contract, the insured
may be contacted by the viatical/life settlement provider (or its
authorized representative) licensed in the state in which you resided at
the time of the viatical/life settlement contract for the purpose of
determining the insured’s health status and to confirm the insured’s
residential
or business street address and telephone number, or as
otherwise provided by Oklahoma law. This contact will be limited to
no more frequently than once every three (3) months if the insured ha
s
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. 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 y
our legal advisor prior to signing it.
14. 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 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.OK.EF11/08 © 2008 Welcome Funds Inc
- 9 -
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.OK.EF11/08 © 2008 Welcome Funds Inc
- 10 -
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.OK.EF11/08 © 2008 Welcome Funds Inc
- 11 -
APPENDIX U. Informational Brochure To Be Provided To A Prospective Viator At First Contact Pursuant To O.A.C. 365:25-11-6(a)
Questions to Ask
• Do I still need life insurance
protection?
• If I sell my policy, how do they
decide how much cash I get?
• Is this an employer or other group
policy? If so, do I need permission
to sell it?
• If I sell my policy, who will be the
legal owner?
• Do I need the advice of a tax or
estate planning advisor before I
decide to sell my policy?
• Who will have specific information
about me, my family or my health
status?
• After I sell my policy, can it be
resold by the buyer?
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 State
Contact your state insurance or
securities departments to learn
about the issues and risks of viatical
settlements if:
• you’re considering selling your
life insurance policy;
• you’re asked to sell your life
insurance policy and your health
hasn’t changed since you bought
the policy;
• you’re asked to buy a new life
insurance policy and
immediately sell it for cash.
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.
Selling
Your Life
Insurance
Policy
Understanding
Viatical
Settlements
2401 NW 23rd Street, Suite 28
Toll Free Phone: 800-522-0071
Phone: 405-521-2828 Fax: 405-522-3642
Email: feedback@oid.ok.gov
Website: www.ok.gov/oid
State Insurance
Department
3
OKLAHOMA INSURANCE
DEPARTMENT
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.
Th
e buyer (the viatical settlement
provider) becomes the new owner
of the life insurance policy, pays
future premiums, and collects the
death benefit when the insured
dies.
At one tim
e, most viatical
settlements were from people with
a life-threatening illness. Now,
individuals who are not facing a
health crisis may sell their life
insurance policies to get cash.
Your st
ate 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 y
ou’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 company if you
have any
cash value in your life in
surance
pol
icy. You may be able to use some of th
e cash
value to m
eet your imme
diate needs and keep
y
our policy in force for your beneficiarie
s. You
may also be able to use the cash value as security
fo
r 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
deat
h benefit before the insured dies. It may
be
a way
for you to get cash from a policy without
selling it to a third p
arty.
Consumer tips
• Comparison shop. Get quotes from
several companies to make sure y
ou
h
ave a competitive o
ffer.
• Fin
d out the tax implications. No
t all
proceeds received from the sale of your
life insurance policy are tax free.
• It
’s important to know that any of y
our
creditors could claim your cash
settlem
ent
.
• Find out if you will lose any public
assi
stance benefits such as food stam
ps
or Medicaid if you get a cash
settlem
ent
.
• The buyer of your policy can
peri
odically ask you about your health
status. The buyer is required to gi
ve
yo
u a privacy notice outlining who
will
g
et this personal information. Be sure to
read it.
• Check all application forms for
accuracy, especially your medical
history. All questions must be answered
truthfully and completely.
• Make sure the viatical settlement
provider agrees to put your settlement
proceeds into an independent escrow
account
to protect your funds during th
e
transfer.
• Find out if you have the right to change
your m
ind about the settleme
nt AFTER
y
ou get the money. If so, how many
days do you have to reconsid
er and
return the m
oney?
4
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

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

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 26 June 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document