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State of California
Department of Insurance
Life Settlement Broker
Disclosure to Owner and Insured
(To be provided prior to the execution of the life settlement contract)
IMPORTANT: READ THIS DISCLOSURE FORM BEFORE SIGNING ANY LIFE SETTLEMENT CONTRACT.
The commissioner may consider any failure to provide the disclosures in this form as a basis for suspending or
revoking a broker’s license. You should carefully read all of the following and seek financial, insurance, tax and
other advice where appropriate.
1. The name, business address, and telephone number of the life settlement broker are as follows:
Broker’s (printed) name:
Address:
Telephone number:
2. A full, complete, and accurate description of all the offers, counteroffers, acceptances, and rejections relating to the
proposed life settlement contract (including name of party, date made, price and any other material terms) is:
Attached
.
As follows: _____________________________________________________________________________________________________
3. The following affiliation or contractual arrangements exists between the broker and the provider making an offer in
connection with the life settlement arrangement:
None.
As follows:
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
4. To be provided only where the owner of the policy is also the insured: the following life expectancy estimates were
provided in connection with the life settlement:
LE Provider Life Expectancy Estimate
LE Provider
Life Expectancy Estimate
LE Provider
Life Expectancy Estimate
LIFE INSURANCE POLICY INSURED AND OWNER’S ACKNOWLEDGMENT: I have read and fully understand this
disclosure form and have received a copy to keep for my records.
LIFE SETTLEMENT BROKER
By:
Printed Name:
Date:
LIFE INSURANCE POLICY INSURED LIFE INSURANCE POLICY OWNER
By: By:
Printed Name: Printed Name:
Date: Date:
