Fillable Life Settlement Pre-Qualification Form

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Life Settlement Pre-Qualification Form

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File type: PDF

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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
Life Settlement Pre-Qualification Form
Instructions:
1. Complete this pricing request form with the most current information available.
2. S
ubmit an inforce maturity illustration with level premiums, a level net death benefit,
and leaving approximately $100 at the end of the illustrated run.
3. Click Submit and attach the illustration or e-mail pricing@welcomefunds.com.
Name of Submitting Producer/Broker
Producer/Broker Phone
Producer/Broker E-mail
Insured(s) Name (Not Required)
Reason for Sale
Insured 1 Gender
M F
Insured 1 D.O.B.
Insured 2 Gender
M F
Insured 2 D.O.B.
Tobacco Use?
M F Both
Have LE’s been completed on the insured(s)? Y N
If so, write in here:
Conversion Deadline or Lapse Date
Owner State (Required)
Insurance Carrier
Policy Issue Date
Loan Amount on Policy
Policy # (last 4 digits)
Face Value
Premiums to Maturity
Policy AV/CSV & As of Date
PLEASE CHECK 1
BOX PER INSURED
INSURED’S HEALTH & LIFESTYLE DESCRIPTION
1
st
Insured
2
nd
Insured
(Please provide most accurate health depiction – preferably based on insured’s opinion)
GOOD
• Insured lives an active and independent lifestyle, may exercise regularly, travel, work, etc.
• Standard health or better.
FAIR
• Insured lives an average lifestyle primarily independent but with some minor assistance.
• L
ikely rated at least a few tables
.
POOR
• Insured lives with independence but DOES require some assistance and supervision.
• Would be issued highly rated.
SERIOUS
• Insured must be monitored regularly requiring daily or full time supervision.
• W
ould NOT qualify for insurance whatsoever.
TERMINAL
• A terminal condition that may result in a life expectancy of 24 months or less.
Primary Diagnosis and Other Medical Conditions
Cancer (5+ yrs in Remission)
Type _____________________
Cancer (current)
Type _____________________
TIA, Multiple? Y__ N__
Stroke (CVA), Multiple? Y__ N__
Hepatitis C
Cirrhosis, Stage ____________
Organ Transplant ___________
Morbid Obesity, BMI% _______
Severe Depression
Sedentary
ADL Assistance with __________
Hypertension - Poor Control
Diabetes (type II) - Controlled
Diabetes (type II) – Poor Control
Parkinson Disease
Dementia
Alzheimer’s Disease
COPD, Stage ________________
Emphysema, Stage ___________
Aneurysm
CKD, Stage _________
Heart Attack, Multiple? Y__ N__
Peripheral Vascular Disease
Valve Replacement/Repair
Atrial Fibrillation
Short-Term Memory Loss
Cardiac Arrhythmia
Congestive Heart Failure
Coronary Artery Disease
Coronary By-Pass
Multiple Sclerosis
Pacemaker Placement in ___
ALS – Diagnosed in _______
Other __________________
Additional Health Notes
:
1
|
2 1
|
2 1
|
2
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Life Settlement Pre-Qualification Form

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Completed 24 June 2021

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