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

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

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FORM WFI.WELCOME.EF2/08 © 2008 Welcome Funds Inc
WELCOME FUNDS INC.
4755 TECHNOLOGY WAY
SUITE 202
BOCA RATON, FL 33431
TOLL-FREE: 877.227.4484
PHONE: 561.862.0244
FAX: 561.862.0242
WWW.WELCOMEFUNDS.COM
LETTER FROM THE PRESIDENT
Dear Policy Owner/Insured:
Thank you for choosing WELCOME FUNDS INC to help you determine and identify the merits and value of
selling your policy. We understand that the process can be intimidating and overwhelming and it is our job to
not only maximize the sales value of your policy(ies) in the secondary market, but also to provide a seamless,
transparent and fully informed experience. Please complete our Evaluation Request for Sale of Existing Life
Insurance and sign the appropriate pages.
As your designated broker who represents your best interests and follows your instructions, WELCOME
FUNDS INC incurs the necessary, required and related costs to facilitate the potential sale of your policy related
to the following services:
• Evaluation Form assessment.
• Medical underwriting and insurance verifications.
• Obtaining and forwarding independent third party life expectancy reports.
• Submission to multiple authorized and/or registered buyers of life insurance policies.
• Best execution negotiation to maximize fair market value of the sale of your policy.
• Closing services including contract review and assistance with contingency requirements of buyers of
life insurance policies.
Please read the Notice of Disclosure and the Broker Authorization and Services Agreement carefully and sign
accordingly. These pages represent the first step in explaining your rights and obligations associated with the
process. With that said, you are under no obligation to accept any contingent offers secured by WELCOME
FUNDS INC. Furthermore, we have attached a brief brochure issued by the National Association of Insurance
Commissioners (NAIC), a non-profit organization of insurance regulators from all 50 states, to provide an
unbiased, independent description of selling policies in the secondary market. Please read the NAIC material as
well.
Please be advised that the personal information acquired shall only be shared with individuals and entities with
an identifiable need to help determine the market value of your policy, including but not limited to life
expectancy underwriters and potential buyers of your policy. All parties involved in the analysis, evaluation,
underwriting and contingent pricing for transactions are required to maintain strict privacy and confidentiality
safeguards pursuant to applicable state and federal regulations.
Once again thank you for allowing us the opportunity to help you reach your financial goals and to represent
you in the secondary market for the potential sale of your life insurance policy.
Sincerely,
John M. Welcom
President
WELCOME FUNDS INC.
4755 TECHNOLOGY WAY
SUITE 202
BOCA RATON, FL 33431
TOLL-FREE: 877.227.4484
PHONE: 561.862.0244
FAX: 561.862.0242
WWW.WELCOMEFUNDS.COM
State
of Utah
Life Settlement Producer Authority
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 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.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 CONSIDERIN
G 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 re
placement policy
Interested in learning market value of policy Cash liquidity preferred due to current finan
cial situation
Other or provide further details: __________________________________________________________________________________
All
Policy Owner(s) and Insured(s) please sign at the bottom of the page, regardless of whether you complete all of the financial
information below.
Please be advised that any Policy Owner(s) and/or Insured(s) who declines t
o provide full and complete financial data acknowledges and
accepts responsibility that such lack of data will impede Welcome Funds Inc’s ability to provide recommendations it deems suitable,
based on personal and specific financial needs, conditions and situations.
Check here if you choose NOT to complete some or all of the requested financial information below (and sign below).
II. INVESTMENT PROFILE
(PLEASE USE COMBINED FIGURES FOR JOINT ACCOUNTS):
INVESTMENT OBJECTIVES: Capital Preservation Income Capital Appreciation/Growth Speculation
(check all that apply)
POLICY OWNER’S TAX BRACKET: 10% 15% 25% 28% 33% 35%
POLICY OWNER’S NET WORTH: $0 - $49,999 $50,000 - $99,999 $100,000 - $199,999 $200,000 -$499,999
$500,000 - $999,999 $1,000,000 - $2,499,999 $2,500,000 and up
ESTIMATED INSURABLE CAPACITY FOR INSURED(S): $________________________________________________________
TOTAL AMOUNT OF IN-FORCE LIFE INSURANCE COVERING INSURED(S): $_____________________________________
III. PLEASE CERTIFY THE CURRENT ACCREDITED INVESTOR STATUS OF THE POLICY OWNER:
THE POLICY OWNER IS CONSIDERED AN ACCREDITED INVESTOR: YES NO
(Refer to the definitions below to answer the above question and if “yes,” then please check the appropriate description)
________
INDIVIDUALS:
1. An individual that has a net worth or joint net worth, with the individual’s spouse, in excess of $1,000,000. “Net worth” for these
purposes is defined as the value of total assets at fair market value, including but not limited to non-primary residence home (the
value of the primary residence, as of July, 2010, is excluded), home furnishings and automobiles, less total liabilities; or
________
2. An individual that (i) had income (exclusive of any income attributable to the individual’s spouse) of more than $200,000 for
each of the past two years or joint income with the individual’s spouse in excess of $300,000 in each of those years, and (ii)
reasonably expects to reach the same individual income level, or the same joint income level, as the case may be, in the current
year; or
________
ENTITIES:
3. A corporation, partnership, limited liability company, Massachusetts or similar business trust or tax-exempt organization as
defined in Section 501(c)(3) of the Code, that (i) has total assets in excess of $5,000,000, and (ii) was not formed for the specific
purpose of investing in the life insurance policy and then selling it; or
________
4. A revocable trust which may be amended or revoked at any time by the grantors thereof, and of which all of the grantors are
accredited investors under either (1) or (2) above; or
________
5. A trust (i) that has total assets in excess of $5,000,000, (ii) that was not formed for the specific purpose of acquiring the life
insurance policy and then selling it, and (iii) whereby the investment decisions are directed by a person who has such knowledge
and experience in business and financial matters and who can evaluate the merits and risks of its investments; or
________
6. A trust for which a bank or savings and loan association is acting as fiduciary in directing investment decisions; or
________
7. An entity whose equity owners are each “accredited investors” i.e., persons meeting the requirements set forth in either of (1) or
(2) above.
Verified and Confirmed By:
___________________________________________ _________________________________ ________
Signature of Primary Insured Printed Name Date
___________________________________________ _________________________________ ________
Signature of Secondary Insured (if applicable) Printed Name Date
___________________________________________ _________________________________ ________
Signature of Policy Owner #1 (if not Insured) Printed Name Date
_________________________________ ________
Printed Name Date
FORM WFI.EF5/08 © 2008 Welcome Funds Inc
- 4 -
PERSONAL ACKNOWLEDGEMENTS
I. Do you have a referring advisor/broker authorized, on your behalf, to a) represent your interests regarding this Evaluation
Request & potential transaction; & b) to accept offers, if any, for the sale of your existing life insurance policy?
Yes No
If Yes, then please provide the name(s) of such advisor(s)/broker(s) below:
____________________________________________________ _____________________________________________________
Name of Referring Advisor /Broker #1 Name of Referring Advisor/Broker #2 (if applicable)
II. Have you signed a Power of Attorney (POA) granting a legal representative to act on your behalf or do you have a
Guardian ad Litem or similar legal representative acting on your behalf regarding this Evaluation Request & Potential
Transaction?
Primary Insured: Yes No Policy Owner #1: (if not Insured): Yes No
Secondary Insured (if applicable): Yes No Policy Owner #2 (if applicable): Yes No
If Yes, then please 1) attach the applicable legal documents to this Evaluation Request; 2) have the legal representative of
the insured sign the “Authorization for Disclosure of Protected Health Information” forms for the primary and secondary
insured as applicable; and 3) provide the names of such legal representative(s) below:
__________________________________________________ __________________________________________________
Name of Legal Representative of Primary Insured (if applicable) Name of Legal Representative of Policy Owner #1 (if applicable)
__________________________________________________ __________________________________________________
Name of Legal Representative of Secondary Insured (if applicable) Name of Legal Representative of Policy Owner #2 (if applicable)
III. How did you learn about the option to sell your insurance policy?
Through my/our own knowledge and/or research and asked to receive this Evaluation Request.
Through my/our referring advisor/broker.
IV. Was this insurance policy premium financed?
Yes No
If yes, then please 1) attach all finance documents, including contracts, trusts and/or corporate documents etc…in order to
evaluate and determine the validity and legality of this potential transaction for insurable interest; 2) provide the name of
the financing company: _____________________________________________________.
Name of Financing Company (if applicable)
I/We represent that the information contained in this Evaluation Request for Sale of Existing Life Insurance is correct and accurate
and acknowledge that WELCOME FUNDS INC may rely on such information, including but not limited to the Personal
Acknowledgements above. I/we will immediately notify WELCOME FUNDS INC of any changes.
I/We give my/our consent to WELCOME FUNDS INC, its agents and/or authorized representatives to release and/
or 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.UTDISC.EF4/09 © 2009 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 a life settlement contract is guilty of a crime & may be subject to fines & confinement in prison.
1. Welcome Funds Inc and your referring advisor/producer, if any,
represents only you and shall 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. So
me or all of the proceeds of your life settlement may be taxable
under federal and state income tax. Welcome Funds Inc is not a
tax advisor and recommends that you consult your own
professional tax advisor regarding this transacti
on.
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. Life settlement proceeds could be subject to the claims of
creditors.
5. There may be possible alternatives to selling your life insurance.
This may include the option of an accelerated death benefit or
policy loans offered by your life insurance company. You are
advised to consult a financial advisor, certified public accountant
and/or an attorney regarding these potential alte
rnatives.
6. Once you have received your proceeds from the sale of your life
insurance policy, you will have fifteen (15) calendar days from
receipt of the life settlement proceeds in which to rescind the
transaction as provided by Utah Law. If the insured dies during
the rescission period, then the settlement is deemed to have been
rescinded, subject to repayment of all settlement proceeds and
any premiums, loans and loan interest to the life settlement
provider or purchaser.
7. Funds will be sent to you within three (3) business days after the
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
beneficiary has been designated. Welcome Funds Inc and your
referring advisor/broker, if any, has no access to or control over
life settlement provider funds that are set aside in escrow or trust.
8. Entering into a 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. Assistance should be sought from a financial advisor.
9. Total compensation payable to Welcome Funds Inc and your
referring advisor/producer, 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 life settlement provider reduced by the total compensation as
described above.
10. All medical, financial or personal information solicited or obtained
by a life settlement provider or producer 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 this information, you will be asked to consent to the
disclosure. The information may be presented to someone who buys
the policy or provides funds for the purchase. You may be asked to
renew your permission to share information every two (2) years. In
addition, information regarding the policy owner’s and insured’s
identity and insured’s medical condition will 1) be shared with the
insurer that issued the life insurance policy; and 2) shall be available
to each subsequent owner of the life insurance policy.
11. The insured may be contacted for the purpose of determining the
insured’s health status and to confirm the insured’s residential or
business address and telephone number. This contact shall be limited
to 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. All such
contacts shall only be made by a life settlement provider licensed in
the state in which the owner resided at the time of the life settlement,
or by the authorized representative of a duly licensed life settlement
provider.
12. Welcome Funds Inc recommends that you read the life settlement
contract and seek assistance from a professional financial advisor
and/or consult with your legal advisor prior to signing it.
13. I/we confirm and acknowledge that Welcome Funds Inc ha
s
provided me/us with a brochure developed and/or approved by the
National Association of Insurance Commissioners (NAIC)
describing the process of life settlements.
I/We acknowledge that I/we have read & 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
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
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 life settlement providers
and producers 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 life
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
securities department before you
make a decision.
Selling
Your Life
Insurance
Policy
Understanding
Life
Settlements
Tel: 555 555 5555
© 2004 National Association of Insurance Commissioners
What is a Life
Settlement?
A life settlement is the sale of a
life insurance policy to a third
party. The owner of the life
insurance policy sells the policy
for an immediate cash benefit.
The buyer (the life 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 time, most life
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 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 company if you have
any cash value in your life insurance
policy. You
may be able t
o use some of the cash value to meet
your immediate needs and keep your policy in
force for your beneficiaries. You may also be ab
le
to use the
cash value as security for a loan from
a
fin
ancial institutio
n.
2
. Find out if your life insurance policy has an
accelerated death benefit. An accelerated de
ath
bene
fit typically pays some of the policy’s deat
h
bene
fit before the insured dies. It may be a way
for you to get cash from a policy without selling
it
to
a third pa
rty.
Consumer
tips
• Comparison shop. Get quotes from
several companies to make sure you
have a competitive offe
r.
• Fin
d out the tax implications. No
t
all proceeds
received from
the sale of
yo
ur life insurance policy are tax
free.
• It’s im
portant to know that any of
your creditors could claim
your cash
settle
ment
.
• Fin
d out if you will lose any pub
lic
assistance
benefits such as
food
sta
mps or Medicaid if you get a cas
h
settle
ment
.
• Th
e buyer of your policy can
periodically ask you about your
health status. The buyer is required
to
give you a privacy notice outlining
who
will get this person
al
inf
ormation. Be sure to read it
.
• Check all application
form
s for
accuracy, espe
cially your me
dical
hi
story. All questions must be
answered truthfully and comp
letely.
• Mak
e sure the life settlement
provider agrees to put your settlement
proceeds into an independent escrow
account to protect your funds
during
th
e tran
sfer.
• Fin
d out if you have the right to
change your mind about th
e
settle
ment AFTER you ge
t the
m
oney. If so, how many days do you
have to reconsider and return th
e
m
oney?
© 2004 National Association of Insurance Commissioners
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Life Settlement Application Form - For Utah Residents (Welcome Funds)

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Completed 26 June 2021

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