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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 New York
Life Settlement Broker License
FORM WFI.WELCOME.EF1/16 © 2016 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
Dea
r 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 Loansif 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 New
York State Insurance Department titled, "Selling Your Life Insurance Policy - Understanding Life Settlements"
to provide an unbiased, independent description of selling policies in the secondary market.
As a reminder, you are under no obligation to sell your life insurance policy, in fact, if you need your coverage and can
afford to maintain it, we highly recommend that you do so!
Once again, thank you for allowing us the opportunity to help you reach your financial goals and to represent you in the
secondary market for the potential sale of your life insurance policy.
Sincerely,
John
M. Welcom
Founder & CEO
FORM WFI.EF1/16 © 2016 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
This request is not an agreement to purchase your policy and you are under no obligation to sell your policy by completing this form.
The information that you provide in this request shall be used to evaluate and prepare your file, as required, to attempt to
negotiate and secure a conditional offer or offers for the potential sale of your existing life insurance policy.
PRIMARY INSURED’S INFORMATION
PRIMARY INSURED NAME (FULL LEGAL NAME) DATE OF BIRTH SOCIAL SECURITY NUMBER TELEPHONE NUMBER
CURRENT HOME ADDRESS 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
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
Single
Married
Divorced
Widowed
PLEASE CHECK APPICABLE MARITAL STATUS IF MARRIED/DIVORCE/WIDOWED, PLEASE PROVIDE FULL NAME OF (EX)SPOUSE
SECONDARY INSURED’S INFORMATION
(If Applicable – 2
ND
To Die / Survivorship Policies Only)
SECONDARY INSURED NAME (FULL LEGAL NAME) DATE OF BIRTH SOCIAL SECURITY NUMBER TELEPHONE NUMBER
CURRENT HOME ADDRESS 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
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 medical information, then please attach a separate sheet with complete details.
FORM WFI.EF1/16 © 2016 Welcome Funds Inc
- 2 -
LIFE INSURANCE POLICY INFORMATION
LIFE INSURANCE COMPANY FACE AMOUNT POLICY NUMBER ISSUE DATE
YES
NO
POLICY LOAN AMOUNT (IF ANY) ACCUMULATED/CASH VALUE (IF ANY) CASH SURRENDER VALUE (IF ANY) CASH VALUE USED TO PAY PREMIUMS?
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 OR YOUR HR DEPT. CONTACT
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 NAMES AND RELATIONSHIP OF ALL PRIMARY BENEFICIARIES OF POLICY (IF IT IS A TRUST, PROVIDE TRUST NAME AND NAME & ADDRESS OF TRUSTEE(S))
ADDITIONAL BENEFICIARIES AND/OR CONTINGENT BENEFICIARIES
POLICY OWNER INFORMATION
If Individually Owned (if Insured is 100% Owner, skip to Bankruptcy Status):
LEGAL NAME OF POLICY OWNER # 1 RELATIONSHIP TO INSURED SOCIAL SECURITY NUMBER
POLICY OWNER # 1 ADDRESS CITY STATE ZIP CODE TELEPHONE NUMBER
LEGAL NAME OF POLICY OWNER # 2 (IF APPLICABLE) RELATIONSHIP TO INSURED SOCIAL SECURITY NUMBER
POLICY OWNER # 2 ADDRESS CITY STATE ZIP CODE TELEPHONE NUMBER
IF THERE ARE MORE INDIVIDUAL 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 A POLICY OWNER EVER DECLARED BANKRUPTCY? IF SO, HAS IT BEEN DISCHARGED? (PLEASE PROVIDE ALL BANKRUPTCY DOCS) WHEN WAS IT DISCHARGED?
If Corporate or Trust Owned:
LEGAL NAME OF COMPANY OR TRUST RELATIONSHIP TO INSURED TAX ID NUMBER
COMPANY OR TRUST ADDRESS (OFFICIAL DOMICILE) CITY STATE ZIP CODE TELEPHONE NUMBER
LEGAL NAME OF AUTHORIZED COMPANY OFFICER OR TRUSTEE # 1 LEGAL NAME OF AUTHORIZED COMPANY OFFICER OR TRUSTEE # 2
TRUSTEE # 1 ADDRESS (IF DIFFERENT THAN TRUST) CITY STATE ZIP CODE TELEPHONE NUMBER
TRUSTEE # 2 ADDRESS (IF DIFFERENT THAN TRUST) CITY STATE ZIP CODE TELEPHONE NUMBER
For multiple policies, please reprint this page, then complete the above information and sign an insurance authorization form for each policy.
FORM WFI.EF1/16 © 2016 Welcome Funds Inc
- 3 -
ADDITIONAL INFORMATION
PLEASE PROVIDE REASONS FOR INTEREST IN SELLING POLICY(IES), CHECK ALL THAT APPLY:
Planning to lapse, cancel, or surrender the policy
Proceeds from sale will help pay for medical treatments
Health & living expenses are a financial burden
Considering a 1035 Exchange or replacement policy
Premium costs have become unaffordable
Cash liquidity preferred due to current financial situation
Original purpose of policy no longer exists
Higher estate tax exemptions has eliminated need for policy
Other or provide further details: _____________________________________________________________________________
PLEASE VERIFY LEGAL CAPACITY OF POLICY OWNER(S) & INSURED(S):
If you choose to accept a contingent offer as a result of this preliminary application process, each individual Policy Owner(s)
and Insured(s) may be required to have a Letter of Competency completed by an attending physician in order to verify their
legal capacity to enter into an agreement to sell the life insurance policy. If the legal capacity of any party is questionable, we
recommend obtaining an official Power of Attorney or Guardian ad Litem for that signatory as soon as possible.
Is there an existing Power of Attorney (POA) granting a legal representative the authority to act on behalf of a signatory or is there
a Guardian ad Litem or similar legal representative acting on their 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) provide a full copy of the applicable legal documents (Durable POA or Medical POA) to verify the authority to sign on
behalf of the signatory;
2) have the legal representative sign all signature lines for that party; 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)
PLEASE VERIFY SOURCE OF PREMIUM PAYMENTS AND/OR ASSIGNMENT OF POLICY:
1) Did the policy owner use a third-party to finance the premium payments? Yes No
If Yes, then please:
a) attach all loan documents, including contracts, trusts and/or corporate documents; and
b) provide the name of the lender/financing company: __________________________________________________
Name of Lender/Financing Company
2) Is the life insurance policy being used as collateral for a loan or is there a current lien or assignment recorded with the life
insurance carrier?
Ye
s
No
If Yes, please provide all loan documents & name of lienholder/assignee: __________________________________________
Name of Lienholder/Assignee
PLEASE VERIFY YOUR MARKET REPRESENTATION:
Are you working with any other third-party, other than Welcome Funds, related to the potential sale of your life insurance policy?
Yes No
If Yes, please check all that apply:
Financial Advisor
Life Agent
Attorney/CPA
Settlement Broker
Direct Buyer
Direct Lender
FORM WFI.EF1/16 © 2016 Welcome Funds Inc
- 4 -
PERSONAL ACKOWLEDGEMENTS
A. 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 as my/our broker
for the potential sale of my/our life insurance policy. I/we also acknowledge that it is my/our responsibility
to notify WELCOME FUNDS INC of any changes to this information, including any changes in health of the insured
after this form has been submitted.
B. I/We understand that the market value of my/our life insurance policy is based in part on the health status and life
expectancy of the insured. Current medical records for the insured are vital to obtain life expectancy assessments. These
assessments are conducted by independent third-party life expectancy providers as required by the marketplace.
WELCOME FUNDS INC is not responsible for the conclusions of these life expectancy providers and does not have the
expertise to dispute those conclusions.
C. I/We acknowledge that WELCOME FUNDS INC is my/our broker who represents my/our best interests during the entire
transaction process. I/We also understand and acknowledge that WELCOME FUNDS INC issues no guarantee that an
offer will be secured for my/our policy.
D. I/We give my/our consent to WELCOME FUNDS INC, its agents and/or authorized representatives to release and/
or transmit electronically all financial, insurance, medical and personal 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 review the information.
E. I/We acknowledge that this Evaluation Request for Sale of Existing Life Insurance may become part of my/our contract
for the sale of my/our existing life insurance policy if my/our 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 existing life insurance policy(ies).
F. I/We acknowledge that I/we have been provided the following address/department to direct any consumer complaints
that I/we may have: WELCOME FUNDS INC c/o Customer Complaints, to 4755 Technology WaySuite 202, Boca
Raton, FL 33431.
G. I/We understand and acknowledge that WELCOME FUNDS INC does not provide any advice as to whether or not to
proceed with the sale of my/our life insurance policy and I/we are free to accept or decline any offer.
H. I/We understand and acknowledge that the policy owner is fully responsible for the timely payment of any and all
premiums due for the policy that is the subject of this potential transaction, on the applicable due dates, up until change
of ownership of the policy occurs, if a transaction is effectuated. I/We, not WELCOME FUNDS INC, assume sole
responsibility if the policy lapses for failure to make timely payment of any and all premiums.
I. I/We would like to consider the following options in addition to a lump sum cash settlement offer (subject to availability
based on state residency, policy types and qualification requirements):
Retained Death Benefit (RDB) Cash Settlement with RDB Life Insurance Loan/Credit Line
Expedited Bid Program (may require additional disclosures)
Fraud Warning: Any person who knowingly presents false information in an application for insurance or a
viatical/life settlement contract is guilty of a crime & may be subject to fines & confinement in prison.
I/We acknowledge that I/we have read and understand the information provided above.
___________________________________________ _________________________________ ________
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 applicable & if not Insured) Printed Name Date
FORM WFI.NYPRIVACY.EF11/09
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
NEW YORK PRIVACY ACKNOWLEDGEMENT & AUTHORIZATION
The following Section, in part, of the New York Insurance Code addresses the way your personally identifiable information,
including without limitation, your financial, medical and insurance related information, is permitted to be disclosed. With
your required signature, you are acknowledging the law as indicated below and authorizing your consent to such disclosure.
Section 7810. Privacy.
(A) Except as otherwise permitted or required by law, no life settlement provider, life settlement broker, or life settlement
intermediary, or any authorized representative thereof, insurer, information bureau, rating agency or company or any other
person with actual knowledge of an insured or owner’s identity, shall disclose the identity of the insured or owner, or any
information that there is a reasonable basis to believe could be used to identify the insured or owner, or the insured’s financial
or medical information, to any person unless the disclosure is:
(1) Necessary to effect a life settlement contract between the owner and a life settlement provider and the owner and
insured have provided prior written consent to the disclosure;
(2) Necessary to effectuate the sale or transfer of a life settlement contract or a settled policy, or interest therein,
provided that every sale is conducted in accordance with applicable state and federal law and provided further
that the owner and the insured have both provided prior written consent to the disclosure;
(3) Provided in response to an investigation or examination by the superintendent, any other governmental officer or
agency, or a self-regulating entity established pursuant to federal securities law;
(4) A term or condition to the transfer of a policy by one licensed life settlement provider to another licensed life
settlement provider, in which case the receiving life settlement provider shall be required to comply with the
confidentiality requirements of this section;
(5) Necessary to allow the life settlement provider or life settlement broker, or any authorized representative thereof
to administer the insurance policy, or to make contacts for the purpose of determining health status as authorized
by New York law, which states that such contact shall be limited to once every three (3) months for an insured
with a life expectancy of more than one (1) year, and to no more than once per month for an insured with a life
expectancy of one (1) year or less. For the purposes of this article, the term “authorized representative” shall not
include any person who has or may have any financial interest in the life settlement contract other than a licensed
life settlement provider, licensed life settlement broker, financing entity, related provider trust or special purpose
entity; further a life settlement provider or life settlement broker shall require its authorized representative to
agree in writing to adhere to the privacy provisions of this article;
(6) Required to purchase insurance; or
(7) Otherwise permitted by regulation promulgated by the superintendent.
In addition to the acknowledgement and authorization above, with your signature, you are allowing your personally
identifiable information, including without limitation, your financial, medical and insurance related information, to be
transmitted electronically, via e-mail or through a password protected and secure website, to the appropriate parties,
permitted by New York law, who have an identifiable need to facilitate the sale of your life insurance policy.
Acknowledged & Authorized By:
___________________________________________ _________________________________ ________
Signature of Primary Insured Printed Name Date
___________________________________________ _________________________________ ________
Signature of Secondary Insured (if applicable) Printed Name Date
___________________________________________ _________________________________ ________
Signature of Policy Owner #1 (if not Insured) Printed Name Date
___________________________________________ _________________________________ ________
Signature of Policy Owner #2 (if not Insured) Printed Name Date
FORM WFI.NYDISC-PO.EF11/09 © 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
NEW YORK -- NOTICE OF DISCLOSUREPOLICY OWNER
(PAGE 1 OF 2)
Fraud Warning: Any person who knowingly presents false information in an application for insurance
or a life settlement contract is guilty of a crime & may be subject to fines & confinement in prison.
1. Wel
come Funds Inc & your referring advisor/broker, if any, represents exclusively you & not the insurer or provider or
any other person & owes a fiduciary duty to you including a duty to act according to your instructions & in your best
interest notwithstanding the manner in which Welcome Funds Inc & 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 income tax &/or state franchise & income
tax laws. Welcome Funds Inc is not a tax advisor & recommends that you consult your own professional tax advisor
regarding this transaction.
3. The
sale of your insurance policy may affect your eligibility to receive public assistance or other government benefits or
entitlements. Advice on such effects should be obtained from the appropriate government agencies.
4. Lif
e settlement proceeds could be subject to the claims of creditors.
5. Th
ere are possible alternatives to selling your life insurance. This may include the option of an accelerated death benefit
or policy loans offered by your insurer. You are advised to consult a financial advisor, certified public accountant &/or an
attorney regarding these potential alternatives.
6. You hav
e the right to terminate the life settlement contract until fifteen (15) days after receipt of the life settlement
proceeds.
7. Pr
oceeds will be sent to you within three (3) business days after the life settlement provider has received the insurer or
group administrator’s acknowledgment that ownership of the policy or interest in the certificate has been transferred & the
beneficiary has been designated in accordance with the terms of the life settlement contract. Welcome Funds Inc & your
referring advisor/broker, if any, has no access to or control over provider funds set aside in escrow or trust.
8. You ha
ve the right to know the date by which the funds will be available & the transmitter of the funds.
9. En
tering into a life settlement contract & the corresponding change in ownership may cause other rights or benefits,
including conversion rights & waiver of premium benefits, which may exist under the policy or a certificate of a group life
insurance policy to be forfeited. Assistance should be sought from a professional financial advisor.
10. You ha
ve the right to know the following related to compensation, no later than the date the life settlement contract is
signed by all parties:
a) the gross offer or bid that the life settlement provider shall pay pursuant to the life settlement contract;
b) the net amount to be paid to you pursuant to the life settlement contract;
c) the name of each life settlement broker, life settlement intermediary, insurance producer or insurance consultant
that will be compensated by the life settlement provider, or any affiliate, parent corporation or subsidiary of the
life settlement provider; &
d) the amount of compensation that the life settlement provider, or any affiliate, parent corporation or subsidiary of
the life settlement provider, shall provide to a life settlement broker, life settlement intermediary, insurance
producer or insurance consultant, or any affiliate, parent corporation or subsidiary of such broker, intermediary,
producer or consultant pursuant to the life settlement contract.
[A
dditional Disclosures on Next Page]
FORM WFI.NYDISC-PO.EF11/09 © 2009 Welcome Funds Inc
NEW YORK -- NOTICE OF DISCLOSUREPOLICY OWNER
(PAGE 2 OF 2)
F
or purposes of this paragraph, “Gross Offer or Bid” means the total amount of value offered by the life settlement
provider for the purchase of one or more life insurance policies, inclusive of commissions & fees.
Total compensation payable to Welcome Funds Inc & 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 Offer or Bid as paid by the life settlement provider reduced by the total
compensation as described above. Actual compensation shall be disclosed no later than the life settlement contract is
signed by all parties.
11. T
he insured may be contacted by the provider or Welcome Funds Inc, or any authorized representative thereof, for the
purpose of determining the insured’s health status or to verify the insured’s address. This contact is limited to no more
frequently than once every three (3) months if the insured has a life expectancy of more than one (1) year, & no more than
once per month if the insured has a life expectancy of one (1) year or less.
12. I
nformation regarding your identity may be shared with the insurer that issued the life insurance policy & shall be
available to each subsequent owner of the life insurance policy.
13. You have the right to know a) the affiliation or contractual arrangements, if any, between the life settlement provider &
the issuer of the insurance policy to be settled; b) the affiliation or contractual arrangements, if any, between the lif
e
set
tlement provider & any other life settlement provider, or life settlement broker, life settlement intermediary or party
financing the transaction; c) the name, business address, telephone number & e-mail address of the independent third-
party escrow agent; & d) the name, business address, telephone number & e-mail address of the life settlement provider.
In addition, you have the right to inspect or receive copies of the relevant escrow or trust agreements or documents.
14. Welcome Funds Inc recommends that you read the life settlement contract & seek assistance from a professional
financial advisor &/or consult with your legal advisor prior to signing it.
15. I
/we confirm & acknowledge that Welcome Funds Inc has provided me/us with a consumer information booklet
prescribed by the New York Superintendent of Insurance titled, “Understanding Life Settlements - Selling Your Life
Insurance Policy.
I/We acknowledge that I/we have read & understand the disclosures above (1-15).
___________________________________________ _________________________________ ________
Signature of Policy Owner #1 (if not Insured) Printed Name Date
___________________________________________ _________________________________ ________
Signature of Policy Owner #2 (if not Insured) Printed Name Date
___________________________________________ _________________________________ ________
Signature of Authorized Officer of Welcome Funds Inc Printed Name Date
FORM WFI.NYDISC-INS.EF11/09 © 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
NEW YORK -- INSURED 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. You m
ay be contacted by the life settlement provider or Welcome Funds Inc, or any authorized representative thereof,
for the purpose of determining your health status or to verify your address. This contact is limited to no more frequently
than once every three (3) months if you have a life expectancy of more than one (1) year, & no more than once per month
if you have a life expectancy of one (1) year or less.
2. A change of ownership could in the future limit your ability to purchase future insurance on your life because there is a
limit to how much coverage insurers will issue on one (1) life.
3. All m
edical, financial or personal information solicited or obtained by a life settlement provider or life settlement broker
about you, including your identity or the identity of family members, a spouse or a significant other may be disclosed as
necessary to effect the life settlement contract between the policy owner & provider. If you are asked to provide this
information, you will be asked to consent to this disclosure. The information may be provided 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 your identity & medical condition 1) may be shared with the insurer that issued
the life insurance policy; & 2) shall be available to each subsequent owner of the life insurance policy.
4. Welcome Funds Inc recommends that you read the life settlement contract & seek assistance from a professional
financial advisor &/or consult with your legal advisor prior to signing it.
5. I/we confirm & acknowledge that Welcome Funds Inc has provided me/us with a consumer information booklet
prescribed by the New York Superintendent of Insurance titled, “Understanding Life Settlements - Selling Your Life
Insurance Policy.
I/We acknowledge that I/we have read & understand the disclosures above (1-5).
___________________________________________ _________________________________ ________
Signature of Primary Insured Printed Name Date
___________________________________________ _________________________________ ________
Signature of Secondary Insured (if applicable) Printed Name Date
___________________________________________ _________________________________ ________
Signature of Authorized Officer of Welcome Funds Inc Printed Name Date
FORM WFI.INSAUTH.EF1/16 © 2016 Welcome Funds Inc
WELCOME FUNDS INC.
4755 TECHNOLOGY WAY
SUITE 202
BOCA RATON, FL 33431
TOLL-FREE: 877.227.4484
PHONE: 561.862.0244
FAX: 561.862.0242
WWW.WELCOMEFUNDS.COM
AUTHORIZATION FOR THE RELEASE OF LIFE INSURANCE POLICY INFORMATION
_________________________________________ __________________________________________
Life Insurance Company Policy Number
_________________________________________ __________________________________________
Printed Name of All Policy Owner(s) Printed Name of Insured(s)
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.HIPAA1.EF1/16 © 2016 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.HIPAA2.EF1/16 © 2016 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)
1
Life Settlements — What You Should Know Before Selling Your Life Insurance Policy
What is a Li
fe Settlement?
A life settlement is the sale of a life insurance policy to a third party called a life settlement
provider. The owner of the life insurance policy sells the policy to the life settlement provider
and receives an immediate payment in return.
The life settlement provider becomes the new owner of the life insurance policy, pays any
future premiums and receives the death benefit when the person whose life is insured under the
policy (the insured) dies.
The New York Department of Financial Services wants you to have the facts before you sell
your life insurance policy. This booklet 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 are planning to sell your policy because you need funds to pay expenses, there may be
other options available under your policy that may allow you to keep your policy in force for
your beneficiaries.
Ask your insurance agent or insurance company if your life insurance policy has any cash value.
Generally, life insurance policies allow you to take a policy loan up to the amount of the cash
value. You may also be able to take out some of the cash value to meet your immediate needs.
You should seek the advice of your insurance agent or other professional before using the cash
value of your policy.
Find out if your policy allows you to reduce the amount of the death benefit in order to lower
the amount of premium you are required to pay. If you are planning to sell your policy because
the premiums have gotten too high, this may provide a way to maintain some of the death
benefit in force.
Find out if your policy has an accelerated death benefit. If the insured under the policy is
terminally or chronically ill, you may be able to accelerate some or all of the death benefit while
the insured is still alive.
Other Important Information
Comparison shop. Get quotes from several life settlement providers to make sure you have a
competitive offer.
If you use a life settle
ment broker, the broker represents exclusively you and has the duty to
act in your best interests and according to your instructions.
2
If you use a life settlement broker, he or she is required to disclose the amount of
com
pensation to be paid to him or her by no later than the date the life settlement contract
is
signed.
Find out the tax implications. Not all proceeds received from the sale of your life insura
nce
policy are tax-free.
It is important to know that the proceeds you receive from a life settlement may be accessi
ble
by
your credit
ors.
Find out if you may lose any public assistance benefits, such as supplementary social
security
benefits, food stamps or Medicaid, or other governmental benefits or entitlements
if
y
ou receive proceeds from a life settleme
nt transaction.
The life se
ttlement provider or its authorized representative may
contact the insured for the
purpose of determining his/her health status. The insured may not be contacted more often
than once every
three months if the insured has a life expectancy of more than one y
ear,
and no m
ore than once per month if the insured has a life expectancy of one year or
less.
The insured
’s medical, financial or other personal information may
be disclosed to certain
other parties if the insured has provided written consent for these disclosures.
After a life
settlement provider buys your policy, the provider may resell the policy to ot
her
parties.
You have the right to change your mind about the life settlement transaction AFTER you
receive the proceeds of the life settlement. You have the right to rescind (cancel) the life
settlem
ent contract from the time the contract is signed until fifteen days after you receive
the
proceeds.
If you are asked to or you plan to buy a new life insurance policy with a primary purpose of
selling it to a third party
, then this may be a stranger-originated life insurance
(STOLI)
transaction that is prohibi
ted by the New York In
surance Law.
Questions to
Ask Your Professional Financial Advisor, Insurance Agent, Employer or
other Professional Advisor
•If I sell my policy, will I still need life insurance protection?
•If I sell my policy, will the insured under the policy be able to buy
additional life insurance
on his/her o
wn life?
If I have a group life insurance certificate under an em
ployer or other group
life insurance
policy
, does the policy permit me to sell it?
If you have questions about selling a life insurance policy, life settlements generally or a life
settlement provider, life settlement broker, or life settlement intermediary, you may contact the New
York Department of Financial Services. Visit the Department’s website at http://www.dfs.ny.gov
.