Fillable Number (FEIN) (Arizona)

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Number (FEIN) (Arizona)

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Form E-LSPS (v 20211201)
Page 1 of 3
LIFE SETTLEMENT PROVIDER ANNUAL STATEMENT
For the Year ending
AZ # (see Certificate of
Authority)
December 31, _________________
Life Settlement Provider Name
Federal Employer Identification
Number (FEIN)
Alternative (Assumed) Name / DBA
Home Office Street Address
State
ZIP Code
Mailing Address
State
ZIP Code
Toll-free Phone
Main Phone
FAX Phone
Type of Entity (select only One)
☐ Stock Corporation
☐
Individual
☐
Partnership
☐ Limited Liability Company
☐ Other (Describe)___________________________________________
Date Incorporated/Formed State Where Incorporated/Formed Fiscal Year Ends on
December 31
Other (mm/dd) : _____/_____
CONTACT
PERSON
Name E-mail Address
Street Address City State ZIP Code
Toll-free Phone Main Phone FAX Number
Annual Statement Filing Fee - Make the $300.00 non-refundable annual statement filing fee. ARS § 20-167(A)(8).
F
inancial Condition
Attach a balance sheet and income statement showing the life settlement provider’s financial condition at the year end of
the preceding calendar year. ARS § 20-3210(A).
Ownership Information
Complete Form E-LSP2 with information for each stockholder or owner of the provider except for stockholders owning
less than 10% of the shares of the provider whose shares are publicly traded, partners, officers and employees. Pursuant
to ARS § 20-3202(C), you must provide an updated version of this form within 30 days of a change to the information
provided.
Management Information
Complete Form E-LSP3 with information for each officer, director, member, and partner, and for each designated
employee who shall be authorized to act under the life settlement provider certificate of authority. Submit NAIC Form 11:
Biographical Affidavit for each person listed on Form E-LSP3 form whom Form 11 has not previously been provided.
Obtain Form 11 from http://www.naic.org/industry_ucaa.htm
. A person may not act on behalf of the provider unless the person has been
named on this form as part of the application for the certificate of authority or as a supplement to the application. ARS § 20-3202(D). Report changes
by submitting an updated Form E-LSP3 executed by an officer, director, member, or partner of the provider, along with NAIC Form 11 for each new
person listed.
Reset
Form E-LSPS (v 20211201)
Page 2 of 3
LIFE SETTLEMENT PROVIDER ANNUAL STATEMENT (cont.)
For the Year Ending
AZ# (see Certificate of Authority)
Life Settlement Provider Name
Federal Employer Identification Number (FEIN)
Policy Information. Provide information relating to the immediately preceding calendar year (in other words, enter information for the year ending December 31
that you specified above). Complete additional pages if information for all policy issue years does not fit on one page. Do not include individual transaction data or
information that could be used to identify any owner or insured. ARS § 20-3210(A).
NATIONWIDE
ARIZONA ONLY
Policy Issue year
Total Number of
Policies settled
during the year
Aggregate face value of
policies settled during
the year
Life settlement proceeds
of policies settled during
the year
Total number of
policies settled
during the year
Aggregate face value of
policies settled during
the year
Life settlement
proceeds of policies
settled during the year
Total
0
$ 0
0
0
$ 0
0
Form E-LSPS (v 20211201)
Page 3 of 3
LIFE SETTLEMENT PROVIDER ANNUAL STATEMENT (cont.)
ATTESTATION AND CERTIFICATION
By signing this form, the signatories solemnly swear attest and certify, under penalty of perjury, to all the following:
• All information contained in the annual statement and any attachments, enclosures and supplements thereto, are true, complete and accurate,
to the best of the knowledge and belief of the signatories. ARS § 20-3210(A).
• The life settlement provider, and each of its officers, directors, members, partners and designated employees who shall have authority to act
under the certificate of authority issued to the life settlement provider understand they must comply with ARS §§ 20-3201 et seq. and other
Arizona laws pertinent to acting as a life settlement provider including but not limited to the following provisions:
o Privacy requirements set forth in ARS §§ 20-3205, 20-3211(H), 20-2101 et seq. and applicable federal laws;
o Annual statement requirements set forth in ARS § 20-3210;
o Requirements for viatical and life-settlement contracts set forth in ARS § 44-1841 et seq. (esp. ARS § 44-1850);
o Requirements to only use licensed life settlement brokers to perform life settlement broker activities. ARS § 20-3202(I).
Signature
Date
Printed Name
Title
Signature
Date
Printed Name
Title
Send the application documents to financialfilings@difi.az.gov
.
Make the $300.00 non-refundable annual statement filing fee payment through OPTins (ARIZONA
APPLICATION/RENEWAL FEES) https://www.optins.org/
(there is a $15.00 transaction fee) or mail check
made payable to the Arizona Department of Insurance and Financial Institutions along with a cover letter
to:
Insurance Financial Affairs Division
Arizona Department of Insurance and Financial Institutions
100 N. 15
th
Ave., Suite 261
Phoenix, AZ 85007-2630
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Completed 1 July 2022

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