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Life Insurance Settlement Application

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Life Insurance Settlement Application Powered By Docstoc
					                                                                                             2045 Myrtlewood Road
                                                                                             Baltimore, Maryland 21209
                                                                                             240-401-9313
                                                                                             www.greentrustlifesettlements.com



Life Insurance Settlement Application

Personal Information:


________________________________________________________________________________________________________
Insured’s Name                      Date of Birth         Social Security Number              Sex (M/F)



________________________________________________________________________________________________________
2nd Insured’s Name                  Date of Birth         Social Security Number              Sex (M/F)



_________________________________________________________________________________________________________
Address                                                                 Phone Number



__________________________________________________________________________________________________________
City                                       State                                      Zip Code



Marital Status: (Circle One) a) Single b) Married d) Divorced e) Widowed


If Married Spouse’s name ____________________________


Dependant Children: _____ Yes _____ No – If yes list Names:_________________________________________


Have you claimed bankruptcy: _____ No _____ Yes – If yes, please attach all discharge documents




If Policy owner is different than above:


__________________________________________________________________________________________________________
Exact Name of Policy Owner (Indiv/Corp./Trust – as listed with life insurance carrier)



__________________________________________________________________________________________________________
Policy Owner Address (Address/State of domicile of Indiv/Corp./Trust)

GTLS_VA_1.10                                                                                                              Page 1
                                                                                           2045 Myrtlewood Road
                                                                                           Baltimore, Maryland 21209
                                                                                           240-401-9313
                                                                                           www.greentrustlifesettlements.com




__________________________________________________________________________________________________________
City                                       State                                      Zip Code

________________________________________________                             ___________________________________________
S.S# or Tax ID#                                                              Daytime Telephone


__________________________________________________________________________________________________________
Exact Name of Corporate Officer(s)/Trustee(s) (If Corporate/Trust Owned Policy)




Life Insurance Policy Information:


__________________________________________________________________________________________________________
Insurance Company Name                                                   Policy Number




Date of issue: ____________________________________                  Coverage/Face Amount: $____________________




Annual Premium: $_________________         Last Payment Date: _________________      Next Payment Date:___________________




Loan Amount: $____________________                          Current Surrender Value: $______________________


Type of Policy: (Circle One)   a)Term   b)Whole Life   c) Universal Life Group d) Other


Reason for Life Settlement: _____________________________________________________________________________________



Medical History



________________________________________________________________________________
Insured’s Primary Attending Physician                                                Telephone Number


GTLS_VA_1.10                                                                                                            Page 2
                                                                                                   2045 Myrtlewood Road
                                                                                                   Baltimore, Maryland 21209
                                                                                                   240-401-9313
                                                                                                   www.greentrustlifesettlements.com



Medical History (Continued)

___________________________________________________________________________________________________________
Other Physician/Specialist Seen in Last 5 years                         Telephone Number



___________________________________________________________________________________________________________
Other Physician/Specialist Seen in Last 5 years                         Telephone Number




Terms and Conditions
Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application
containing any false, incomplete, or misleading information may be guilty of a crime and may be subject to fines and/or confinement
in prison. The applicant warrants and represents that all information contained in this application is true and correct to the best of
his/her knowledge. The applicant further gives consent to GreenTrust Life Settlements LLC and its agents to release this application
and all information gathered while processing including, but not limited to all medical records, notes, and lab reports, pertaining to the
applicants health status for the purpose of soliciting the sale of the applicant’s life insurance policy. The applicant acknowledges that
he/she is submitting this application for GreenTrust Life Settlements LLC to evaluate the purchase of the applicant’s life insurance
policy and that GreenTrust Life Settlements LLC is under no obligation to purchase the policy.



_______________________________________________________________________________
Policy Owner/Applicant Signature                                  Print Name                                       Date




_______________________________________________________________________________
Insured’s Signature                                               Print Name                                      Date




GTLS_VA_1.10                                                                                                                        Page 3
                                                                                                    2045 Myrtlewood Road
                                                                                                    Baltimore, Maryland 21209
                                                                                                    240-401-9313
                                                                                                    www.greentrustlifesettlements.com



Notice of Disclosure (Read before signing)
    1.   There may be possible alternatives to selling your life insurance. This may include a) the option of an Accelerated Death
         Benefit offered by your insurance company, b) borrowing against the cash surrender value of the policy itself, or c)
         surrendering the policy for cash value. You are advised to consult a financial advisor, certified public accountant or an
         attorney regarding these potential alternatives. Review all of your options and issues before you decide. This way you can be
         sure you are making a decision that is in your best interest.

    2.   A Life Settlement transaction may be rescinded fifteen (15) calendar days after funds are received by the policy owner
         subject to repayment of all settlement proceeds and any premiums and loan interest paid by the viatical/life settlement
         provider (Purchaser). If the insured dies during the rescission period, then the settlement contract shall be deemed rescinded,
         subject to repayment of all settlement proceeds and any premiums and loan interest paid on your behalf by the viatical/life
         settlement provider (Purchaser).

    3.   Some or all of the proceeds of your viatical/life settlement may be taxable under federal income tax and/or state franchise and
         income tax laws. GreenTrust Life Settlements, LLC is not a tax advisor and recommends that you consult your own
         professional tax advisor regarding this transaction.

    4.   The sale of a life insurance policy may affect your eligibility for Medicaid, supplemental Social Security Income or your
         right to receive other government benefits or entitlements. Advice on such effects should be obtained from the appropriate
         government agencies.

    5.   Funds will be sent to the policy owner within three business days after the viatical/life settlement provider (Purchaser) has
         received the insurer's or group administrator's acknowledgment that ownership of or interest in the policy has been
         transferred and the beneficiary has been designated in accordance with the terms of the life settlement contract. GreenTrust
         Life Settlements, LLC and your referring advisor/broker, if any, has no access to or control over the viatical/life settlement
         provider (Purchaser) funds that are set aside in escrow or trust.

    6.   Entering into a viatical/life settlement contract may 1) cause other rights or benefits, including conversion rights and waiver
         of premium benefits, which may exist under the 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 adviser.

    7.   GreenTrust Life Settlements, LLC, will only process your life insurance policy through licensed providers required as
         applicable. GreenTrust Life Settlements LLC is not affiliated with any viatical/life settlement provider (Purchaser) or Insurer.

    8.   The insured may be contacted by purchaser of the policy or its authorized representative for the purpose of determining the
         insured’s health status. This contact is limited to once every 3 months if the insured has a life expectancy of more than 1
         year, and not more than once per month if the insured has a life expectancy of one year or less.

    9.   Settlement Proceeds of the viatical/life settlement could be subject to the claims of creditors.

    10. All medical, financial or personal information solicited or obtained by a viatical/life settlement provider (Purchaser) or
        GreenTrust Life Settlements, LLC about the insured, including the insured's identity or the identity of family members, a
        spouse, or a significant other may be disclosed as necessary to effect the viatical/life settlement between you and the
        viatical/life settlement provider (Purchaser). If you are asked to provide this information, you will be asked to consent to the
        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 2 years.

    11. Applicant acknowledges that GreenTrust Life Settlements, LLC is not responsible for any failure on the part of a potential
        buyer to purchase Applicant’s policy(s) on terms offered by a potential buyer through GreenTrust Life Settlements, LLC;


GTLS_VA_1.10                                                                                                                       Page 4
                                                                                                   2045 Myrtlewood Road
                                                                                                   Baltimore, Maryland 21209
                                                                                                   240-401-9313
                                                                                                   www.greentrustlifesettlements.com

                                                    {Additional Disclosures on the ext Page}


Notice of Disclosure (Continued)
          applicant acknowledges that GreenTrust Life Settlements, LLC is not responsible for the accuracy of any representations
          made by a potential buyer of applicant’s policy(s) (even if such representations are communicated to Applicant by
          GreenTrust Life Settlements, LLC), and Applicant will look solely to the potential buyer of Applicant’s policy(s) in the event
          that Applicant believes that a potential buyer has made misrepresentations to Applicant of otherwise failed to perform on
          purchase offers or other promises.

     12. A viatical/life settlement broker is a person who on behalf of another and for a fee, commission, or other valuable
         consideration introduces you to viatical/life settlement providers, or offers or attempts to negotiate viatical/life settlement
         contracts between you and one or more viatical/life settlement providers. The viatical/life settlement provider (Purchaser)
         will pay a processing brokerage fee up to six percent of the policy coverage amount without recourse, out of the proceeds
         from the purchase of your insurance policy, directly to GreenTrust Life Settlements, LLC and/or your financial professional.
         The processing brokerage fee is paid directly from the viatical/life settlement provider (Purchaser) on your behalf only upon a
         closed settlement transaction after the applicable rescission period expires; however Virginia law affords you the opportunity
         to pay GreenTrust Life Settlements, LLC directly if you wish by executing a separate agreement.

     13. GreenTrust Life Settlements, LLC recommends that you read the viatical/life settlement contract and seek assistance from a
         professional financial advisor and/or consult with your legal advisor prior to signing it.

     14. Any person who knowingly presents false information in an application for a viatical/life settlement contract is guilty of a
         crime and may be subject to penalty, including but not limited to fines and confinement in prison.

     15. I confirm and acknowledge that GreenTrust Life Settlements, LLC has provided me with the brochure developed by the
         National Association of Insurance Commissioners (NAIC) describing the viatical/life settlement process.


I acknowledge that I have read and understand the contents of this disclosure and all the information provided is true.




____________________________                          ___________________________                            _____________
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




____________________________                          ___________________________                            _____________
GTLS_VA_1.10                                                                                                                      Page 5
                                                               2045 Myrtlewood Road
                                                               Baltimore, Maryland 21209
                                                               240-401-9313
                                                               www.greentrustlifesettlements.com

Signature of Policy Owner #2 (if not Insured)   Printed Name            Date




GTLS_VA_1.10                                                                                Page 6
                                                                                                2045 Myrtlewood Road
                                                                                                Baltimore, Maryland 21209
                                                                                                240-401-9313
                                                                                                www.greentrustlifesettlements.com



Authorization for the Disclosure of Protected Health Information
I, the undersigned, authorize disclosure of my protected health information as defined under the privacy regulations
promulgated pursuant to the Health Insurance Portability and Accountability Act of 1996 (“PHI”) as follows:

1. Classes of Persons Authorized to Disclose My Protected Health Information: I authorize each doctor, hospital, nurse,
pharmacy, physician, physician practice group, and any other type of health care provider (each, an “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
photo static or facsimile copy or other reproduction of this authorization.

2. Classes of Persons Authorized to Receive My Protected Health Information: I authorize each Authorized HCP to disclose
my PHI under this authorization to GreenTrust Life Settlements, LLC including 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 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, brokers/brokerages, 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 or other representatives and the officers, directors and employees (each, an “Authorized Recipient”).

3. Protected Health Information 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 analyze, assess, evaluate or underwrite my
health or medical condition, or life expectancy, in connection with the possible sale of any life insurance policy, or certificate of
life insurance, under which my life is insured. In addition, I acknowledge that some state and federal laws prohibit the further
disclosure of drug, alcohol or HIV related information without specific written consent. This authorization shall serve as such
consent in order for each Authorized Recipient to perform the functions described herein.

4. Expiration: 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 HCP or
other covered entity may condition my treatment, payment, enrollment or eligibility for benefits on whether I sign this
authorization.

I understand that 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”). I further understand that, 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 redisclosure by
the Authorized Recipient and the HIPAA Privacy Regulations may no longer protect my PHI that is disclosed to such
Authorized Recipient. I further understand that my ongoing health status may be tracked as a result of this Authorization.



GTLS_VA_1.10                                                                                                                   Page 7
                                                                                                                         2045 Myrtlewood Road
                                                                                                                         Baltimore, Maryland 21209
                                                                                                                         240-401-9313
                                                                                                                         www.greentrustlifesettlements.com



Authorization for the Disclosure of Protected Health Information (Con’t)

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.



__________________________________________________                           ____________________________________________                       __________
Signature of Insured                                                        Print Name                                                           Date




__________________________________________________                           ____________________________________________                       __________
Signature of Legal Representative of Individual (if applicable)             Print Name                                                           Date



________________________________________________________________________________________________________________________
Description of Legal Representative’s Authority: (Power of Attorney, Guardian ad Litem or similar status – Please attach legal documents for verification)




GTLS_VA_1.10                                                                                                                                                 Page 8
                                                                                             2045 Myrtlewood Road
                                                                                             Baltimore, Maryland 21209
                                                                                             240-401-9313
                                                                                             www.greentrustlifesettlements.com




Policy Service Authorization



________________________________________                    __________________________________________
Life Insurance Company                                      Policy Number(s)




____________________________________                        _____________________________________
Printed Name of Policy Owner(s)                             Printed Name of Insured(s)



I hereby authorize GreenTrust Life Settlements, LLC and its authorized agents as my representative to inquire for and receive
information on the above-mentioned policy(ies). 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, policy forms, riders, illustrations, endorsements or amendments, beneficiary arrangements, dividend option, policy
loans, conversions, current values, verification of coverage, contestable and suicide status, lapse or reinstatement application
and history, confirmation and status of change in ownership designations and any other general information about my coverage.

This Policy Service Authorization shall remain in force until the earlier of two years from the date signed or if it is withdrawn
by me pursuant to applicable law. I further urge that this request be responded to in a timely fashion, as it has a significant
bearing on personal and financial matters. It is my desire that you give GreenTrust Life Settlements, LLC the same cooperation
you would give one of your own agents. A photocopy or facsimile of this authorization shall be considered as valid as the
original. This document may also be signed in counterparts.


Authorized By:




___________________________________                _____________________________                  __________
Policy Owner #1 Signature                          Printed Name                                    Date




___________________________________                _____________________________                  __________
Policy Owner #2 (if applicable) Signature          Printed Name                                    Date




GTLS_VA_1.10                                                                                                               Page 9
                       What is a Viatical                                 Consider Your Options
                       Settlement?
                                                                          If you’re selling your policy to get cash
     State Insurance                                                      to pay expenses, check all of your
                       A viatical settlement is the sale of a life
       Department                                                         options. You may find a way to get more
                       insurance policy to a third party. The owner
                                                                          cash from your life insurance policy.
                       (viator) of the life insurance policy sells the
                       policy for an immediate cash benefit.
                                                                          1.   Ask your insurance agent or
                                                                               company if you have any cash value
                       The buyer (the viatical settlement provider)
                                                                               in your life insurance policy. You
Selling Your           becomes the new owner of the life insurance
                       policy, pays future premiums, and collects the
                       death benefit when the insured dies.
                                                                               may be able to use some of the cash
                                                                               value to meet your immediate needs
                                                                               and keep your policy in force for
Life                   At one time, most viatical settlements were
                                                                               your beneficiaries. You may also be
                                                                               able to use the cash value as security
                       from people with a life-threatening illness.
Insurance              Now, individuals who are not facing a health
                       crisis may sell their life insurance policies to
                                                                               for a loan from a financial
                                                                               institution.
                       get cash.
Policy                 Your state insurance department and
                                                                          2. Find out if your life insurance
                                                                             policy has an accelerated death
                                                                             benefit. An accelerated death
                       the National Association of Insurance                 benefit typically pays some of the
                       Commissioners want you to have the                    policy’s death benefit before the
                       facts before you sell your life                       insured dies. It may be a way for
                       insurance policy. This brochure                       you to get cash from a policy

Understanding
                                                                             without selling it to a third party.
                       provides some of that information, but
                       it is only a starting point. Consult your
Viatical               own professional financial advisor,
Settlements            attorney, or accountant to help you
                       decide if this is the most suitable
                       arrangement for you.
    Consumer tips                                  Questions to Ask                                                  Always Check with
                                                   •
                                                                                                                     Your State
•   Comparison shop. Get quotes from several            Do I still need life insurance protection?
    companies to make sure you have a                                                                       •   Contact your state insurance or securities
    competitive offer.                             •    If I sell my policy, how do they decide how             departments to learn about the issues and
                                                        much cash I get?                                        risks of viatical settlements if:
•   Find out the tax implications. Not all
                                                   •    Is this an employer or other group policy? If so,   •   you’re considering selling your life
    proceeds received from the sale of your life
                                                        do I need permission to sell it?                        insurance policy;
    insurance policy are tax free.
                                                                                                            •   you’re asked to sell your life insurance
•   It’s important to know that any of your        •    If I sell my policy, who will be the legal              policy and your health hasn’t changed
    creditors could claim your cash settlement.         owner?                                                  since you bought the policy;
•   Find out if you will lose any public           •    Do I need the advice of a tax or estate planning
                                                        advisor before I decide to sell my policy?          •   you’re asked to buy a new life insurance
    assistance benefits such as food stamps or
                                                                                                                policy and immediately sell it for cash.
    Medicaid if you get a cash settlement.
                                                   •    Who will have specific information about me,
•   The buyer of your policy can periodically           my family or my health status?
    ask you about your health status. The buyer
                                                                                                                  Buying a Life
    is required to give you a privacy notice       •    After I sell my policy, can it be resold by the           Insurance Policy?
    outlining who will get this personal                buyer?
    information. Be sure to read it.
                                                                                                            If you’re interested in buying a life
•   Check all application forms for accuracy,          Your state insurance department may                  insurance policy as an investment, contact
    especially your medical history. All                                                                    your state insurance department before you
    questions must be answered truthfully and          have a list of viatical settlement
                                                                                                            make a decision.
    completely.                                        providers and brokers that are licensed
                                                       to do business in the state. Contact them
•   Make sure the viatical settlement provider
    agrees to put your settlement proceeds into        to make sure yours are on the list.
    an independent escrow account to protect
    your funds during the transfer.
    Find out if you have the right to change
    your mind about the settlement AFTER
    you get the money. If so, how many days
    do you have to reconsider and return the
    money?

				
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