VIATICAL SETTLEMENT APPLICATION

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VIATICAL SETTLEMENT APPLICATION Powered By Docstoc
					                                                          Welcome to Ashar

              We are experts in the secondary market for life insurance policies specializing in handling the many
              complex details that are part of the settlement process. Our goal is to assist clients wishing to exercise
              their rights as life insurance policy owners and insureds to investigate the possibility of receiving more for
              their policies than may be offered through traditional policy surrenders.

              Our success is built on trusted relationships with many of the nation’s top planning advisors. We earn our
              reputation every day by leveraging our strong relationships with the premiere institutional funding sources
              such as banks and other capital markets groups to benefit our clients.

              You can be certain we respect your privacy and that the personal information you provide us will be
              handled confidentially. We will constantly be focused on your interests throughout the administrative
              process. Our definition of success is an outcome that pleases you.

              When we receive your Inquiry forms, we will begin work on what could be a lengthy process. Timely
              return of these completed forms and necessary documents help us work efficiently. Our energetic,
              experienced staff of industry experts will then navigate the process expeditiously for you.

              Again, welcome. It’s a privilege for us to help achieve your goals. We’re looking forward to success!

              Sincerely,

              Jon B. Mendelsohn
              President and CEO




                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.



              In order to assist processing your Inquiry packet, please provide the following:


                •Referring Advisor Name:                                               •Email:

                •Address:

                •City:                                  •State:                        •Zip Code:                   •Phone:
                •Please Contact:                        •If support staff:
                     Me         Support Staff           •Email:                                                     •Phone:




FORM ASHAR.CVRLTR.INQ10/09.NC                                                                                                             1-1
FORM ASHAR.TL.INQ10/09.NC   2-1
         Dear Policy Owner, Insured and Referring Advisor (if applicable):

         Ashar Group, LLC and its authorized employees, contractors, representatives and agents (“Ashar”) is an independent financial advisory
    firm that focuses on providing market valuations and brokering the sale of existing life insurance policies to purchasers in the secondary
    market. Ashar has no financial or other affiliations with the parties with whom Ashar works with while acting as the Policy Owner’s and
    Insured’s representative. Ashar’s only compensation for its services, which includes but is not limited to policy assessment, obtaining and
    forwarding life expectancy reports, best execution negotiations, medical underwriting, insurance verifications and final contract preparation,
    is determined in accordance with the provisions set forth in Paragraph Seven (7) below. Ashar does not collect any “hidden fees.” Unlike
    other competitive firms, Ashar does not raise capital or report to outside investors. Ashar’s goal is to obtain contingent offers that maximize
    the Policy Owner’s return on the existing policy and to represent his or her best interests throughout the relationship.

         The purpose of this Acknowledgement, Authorization & Agency of Record is to a) disclose to each undersigned certain policies and
    procedures followed by Ashar when brokering the sale of the existing life insurance policy or policies owned by the Policy Owner issued by
    (insert Insurer Name) ____________________________________________________________ with policy number or numbers
    (insert Policy Number(s))________________________________________ (the “Policy” regardless if more than one) in the secondary
    market for life insurance; b) secure the acknowledgements and representations of each applicable undersigned of the information contained
    herein; and c) authorize Ashar to work on behalf of each undersigned. Please be advised that the matters discussed below are not intended
    to be exhaustive of all policies and procedures adhered to by Ashar.

         Each undersigned is identified below (please complete even if Policy Owner and Insured are the same):


     PRINTED NAME OF POLICY OWNER                                               PRINTED NAME OF POLICY OWNER #2 (if applicable)



     PRINTED NAME OF PRIMARY INSURED                                            PRINTED NAME OF SECONDARY INSURED (if applicable)




     PRINTED NAME OF REFERRING ADVISOR #1 (if applicable)                       PRINTED NAME OF REFERRING ADVISOR #2 (if applicable)



         The Acknowledgements and Authorizations of each applicable undersigned are as follows:

    1.   No Policy Owner Obligation: The Policy Owner is under no obligation to accept any contingent offers secured by Ashar.

    2.   Acquiring Contingent Offers: After obtaining all appropriate and requisite releases, Ashar will complete an internal medical review and
         pricing analysis of the Policy. Ashar adheres to strict procedures in the receipt and acceptance of contingent offers. The Policy Owner
         acknowledges that Ashar shall, and the Policy Owner specifically authorizes Ashar to, communicate to prospective purchasers of the
         Policy an “end date” – this is the date after which offers by prospective purchasers will not be accepted. Without an “end date,” the
         process would include a great deal of uncertainty for all parties involved. Ashar shall consult with the Referring Advisor, if applicable,
         regarding the determination of an “end date” and Ashar shall advise potential purchasers of the Policy of the “end date” determined. The
         Policy Owner authorizes the Referring Advisor, if applicable and on his, her or its behalf, to a) determine the “end date;” b) accept and
         decline any and all contingent offers secured by Ashar; c) to communicate to Ashar acceptance of any contingent offer in order for Ashar
         to proceed with the sale of the Policy; and d) represent his, her or its interests regarding the potential sale of the Policy. The Referring
         Advisor, if applicable, in turn, accepts the above authorization. Please be advised that Ashar is relying upon the above authorizations by
         the Policy Owner and each undersigned acknowledges such reliance. If there is no Referring Advisor, then the Policy Owner authorizes
         Ashar, at the direction of the Policy Owner, to a) determine the “end date;” b) accept and decline any and all contingent offers; c) to
         accept any contingent offer in order to proceed with the sale of the Policy; and d) represent his, her or its interests regarding the
         potential sale of the Policy

    3.   Confidentiality: Ashar adheres to strict internal policies and procedures to protect confidential data involving the Policy Owner and the
         Insured. All confidential data furnished to Ashar is only shared with third parties outside of Ashar on a need-to-know basis in
         furtherance of a) establishing the market value of the Policy; and b) the potential sale of the Policy.




FORM ASHAR.AAX.INQ10/09.NC                                                                                                                          3-1
   4.   Additional Authorizations: The Policy Owner and Insured authorize Ashar to a) release and/or transmit electronically all collected
        financial and insurance information to the appropriate parties, as determined by Ashar in good faith, who have an identifiable need to
        facilitate the potential sale of the Policy; b) act as exclusive representative to facilitate the sale of the Policy beginning on the date of the
        Policy Owner’s signature and continuing for a period of one hundred eighty (180) days after the final offer is obtained/acquired for the
        Policy; and c) operate pursuant to its customary and typical business practices in relation to the potential sale of the Policy, including but
        not limited to identifying the type and amount of prospective purchasers and the “end date” described in Paragraph Two (2) above.

   5.   Additional Acknowledgements: Each undersigned acknowledges the following: a) that the commitment to Ashar, for the period of time
        described in Paragraph Four (4) above, excludes facilitating the sale of the Policy with any other entity or individual, including but not
        limited to other financial professionals other than the Referring Advisor, if applicable, pursuant to this Acknowledgement &
        Authorization; b) that this Acknowledgement, Authorization & Agency of Record nullifies any and all previous authorizations designating
        any party, other than Ashar and the Referring Advisor, if applicable, as representative to facilitate the sale of the Policy; c) if the Policy
        Owner does not accept a specific contingent offer, then all work product created in connection with producing such contingent offer shall
        remain the exclusive property of Ashar; d) Ashar issues no guarantee that the Policy will be sold; e) Ashar is under no obligation to
        ultimately locate a purchaser of the Policy or to purchase the Policy itself; f) Ashar is not responsible for any breach committed by a
        potential purchaser of the Policy or any representative of the potential purchaser of the Policy; and g) Ashar, in order to facilitate the
        potential sale of the Policy, requires documentation including but not limited to current in-force illustrations for the Policy, as specified
        by Ashar; copy of two forms of identification for the Policy Owner and Insured; copy of the Policy and the application for the Policy; copy
        of any trust or corporate formation documents indicating ownership of the Policy, if applicable; copy of any divorce decree of the Policy
        Owner and/or Insured, if applicable; copy of any bankruptcy discharge of the Policy Owner and/or Insured, if applicable; and copy of all
        premium finance contracts, if applicable.

   6.   No Intent to Sell Policy: The Policy Owner hereby represents and warrants to Ashar that the Policy Owner did not procure the Policy with
        the intent to sell the Policy.

   7.   Fee Disclosure: The gross fee payable to Ashar and the Referring Advisor, if applicable, for the services associated with the sale of
        the Policy shall collectively not exceed eight percent (8%) of the Net Death Benefit of the Policy, even if in some states fees must
        be directly correlated to the purchase price of the Policy. Based upon Ashar’s experience, the above fee calculation is reasonable
        in the secondary market for the sale of existing life insurance policies and each undersigned acknowledges that such fee
        calculation is reasonable. Please note if Ashar is successful in facilitating the sale of the Policy, the Policy Owner is paid and any
        and all applicable rescission periods have expired, the Policy Owner may be required to pay Ashar, at Ashar’s discretion, all
        necessary transactional costs required by third party service providers associated with the sale of the Policy, including but not
        limited to fees for acquiring life expectancy reports, Policy illustrations and medical records. Please be advised that Ashar shall
        never require reimbursement if such reimbursement shall cause Ashar’s gross fee to be more than the percentage described
        above. In the event that Ashar is unable to successfully facilitate the sale of the Policy and the Policy Owner is not paid, there are
        no fees whatsoever due and owed to Ashar of any kind, unless agreed upon in writing per a separate agreement.

   8.   Funding of Premiums: Except as noted below, the premiums have been funded by the Insured and/or immediate family members of the
        Insured.

        ___________________________________________________________________________________________________

        ___________________________________________________________________________________________________

   9.   Power of Attorney: Except as noted below, the Policy Owner and Insured have not signed a Power of Attorney (“POA”) granting a legal
        representative to act on his or her behalf related to or associated with the potential sale of the Policy.

        If the Insured (Primary or Secondary) has a POA, then please identify below:

        ___________________________________________________________________________________________________

        If the Policy Owner (or any Policy Owner) has a POA, then please identify below:

        ___________________________________________________________________________________________________




FORM ASHAR.AAX.INQ10/09.NC                                                                                                                                  3-2
   10. Referring Advisor Representations (If Applicable): The Referring Advisor, if applicable, represents that he or she: a) is the primary and
       often only direct contact with the Policy Owner to determine suitability and the value and merit of selling the Policy; b) has determined
       that selling the Policy is suitable for the Policy Owner; c) is acting in a fiduciary capacity and always in the best interest of the Policy
       Owner during the potential and/or actual sale of the Policy; d) shall determine the best use of any proceeds from the sale of the Policy;
       and e) understands that Ashar is relying upon the above Referring Advisor representations, if applicable, to move forward with the
       potential sale of the Policy.

       By signing below, each undersigned understands the authorizations, acknowledgements and representations above and has had the
   opportunity to ask any questions or express any concerns regarding this Acknowledgement, Authorization & Agency of Record.




     PRINTED NAME                                      SIGNATURE OF POLICY OWNER                                           DATE



     PRINTED NAME                                      SIGNATURE OF POLICY OWNER #2 (if applicable)                        DATE



     PRINTED NAME                                      SIGNATURE OF PRIMARY INSURED                                        DATE



     PRINTED NAME                                      SIGNATURE OF SECONDARY INSURED (if applicable)                      DATE



     PRINTED NAME                                      SIGNATURE OF REFERRING ADVISOR (if applicable)                      DATE



     PRINTED NAME                                      SIGNATURE OF REFERRING ADVISOR #2 (if applicable)                   DATE



     PRINTED NAME                                      SIGNATURE OF AUTHORIZED REPRESENTATIVE OF ASHAR                     DATE




FORM ASHAR.AAX.INQ10/09.NC                                                                                                                            3-3
    Pre-Submission Checklist: (PLEASE COMPLETE CHECKBOXES BELOW)
         Inquiry completed
         HIPAA/Medical Release completed *
         Insurance Release completed *
         Current Illustrations: Depending on type of policy (see requirements listed below)
            Please check one:                 Advisor will provide            Ashar should obtain with Insurance Release Provided
         Current Account and Surrender Value
         Medical Records – The longer of the last 5 years or 2 years prior to the policy issue date from both Primary Physician and Specialist
            Please check one:                 Advisor will provide            Ashar should obtain with HIPAA/Medical Authorization Provided
         Copy of Policy including application
         Photo ID of Owner and Insured (Driver’s License, State ID Card, or Passport)
         Copy of all Premium Finance Documents, if applicable
         Copy of Trust or Corporate Documents, if applicable
         Referring Advisors Only; all applicable licenses and self-appointments as required by state regulation
                                    *Insurance companies and medical facilities may require additional specific forms

    Illustration Requirements:
    1. Run at current assumptions
    2. Show all loans paid in full in the current policy year

    Additional Requirements per policy type:
    Universal Life:
    1. Run with minimum level premium required to maintain level death benefit to age 100 with $1 - $1000 at maturity.
    2. Run using the minimum guaranteed premium if the policy has a guaranteed no-lapse premium or secondary guarantee.
    3. If the policy has an Increasing Death Benefit or Return of Premium Death Benefit, run a) with the current death benefit option showing
        minimum premium to carry the policy to maturity and b) assuming the death benefit option is changed to level and then showing a level
        premium required to maintain level death benefit to age 100 with $1 - $1000 at maturity.
    Whole Life:
    1. Run showing premium offset in earliest possible year.
    2. Run showing dividends applied to reduce premiums.
    3. If policy has a term rider, the illustrations must show the full death benefit maintained to age 100.
    Term Life:
    1. Term Premium Schedule
    2. If policy is still within the conversion period, a conversion illustration assuming the policy will be converted to the best available
        conversion product, preferably a Universal Life.

      NOTE: In order to obtain the best possible offers for your clients, we may request additional illustrations.

    Contracts/Closing Items Checklist:
        Original or Certified copy of insurance policy (A Certificate of Insurance is not acceptable to most funders)
        Most recent annual statement
        Completed W-9
        Copy of insured’s social security card
        Final verification of policy values by insurance carrier
        Letter of Competency may be required
        Divorce Decree of Policy Owner, if applicable
        Bankruptcy Discharge of Policy Owner, if applicable
        Spousal Consent if policy is individually owned. Also may be required under other circumstances.
        Policies issued within past 3 years
             Premium payment history
             Proof of premium payments
        Previously recorded Change of Ownership or Beneficiary Form if this has changed since policy issuance



FORM ASHAR.CHK.INQ10/09.NC                                                                                                                       4-1
 PERSONAL DATA:

   •Insured’s Name:                                                                   •Date of Birth:                  •Gender:     Male    Female
   •Social Security #:                              •US Citizen?:       Yes      No      •Height:                        •Weight:
   •2nd Insured’s Name:                                                               •Date of Birth:                  •Gender:     Male    Female
   •Social Security #:                              •US Citizen?:       Yes      No      •Height:                        •Weight:
   •Insured's Address:
   •City:                                                    •State:                                           •Zip:


  •Does Insured(s) own residence in another state(s)?               •If yes, provide address and months per year spent at each residence:
      Yes        No
  •Is Client Applying For New Insurance?      Yes       No          •Anticipated Date New Insurance Inforce:

 INSURED MEDICAL INFORMATION (Attach separate page if necessary):

  •Insured Medical History and Conditions:
  •Primary Physician:                                     •Date and Reason Last Seen:
  •Address:                                                                                      •Telephone:
  •City:                                                  •State:                                •Zip:
  •Insured's Specialist:                                  •Specialty:
  •Date and Reason Last Seen:
  •Address:                                                                                      •Telephone:
  •City:                                                  •State:                                •Zip:

  •Hospitalizations:                                      •Date and Reason Last Seen:
  •Address:                                                                                      •Telephone:
  •City:                                                  •State:                                •Zip:

 2ND INSURED MEDICAL INFORMATION (Attach separate page if necessary):

   •2ND Insured Medical History and Conditions:
   •Primary Physician:                                    •Date and Reason Last Seen:
   •Address:                                                                                     •Telephone:
   •City:                                                 •State:                                •Zip:
   •2ND Insured's Specialist:                             •Specialty:
   •Date and Reason Last Seen:
   •Address:                                                                                     •Telephone:
   •City:                                                 •State:                                •Zip:
   •Hospitalizations:                                     •Date and Reason Last Seen:
   •Address:                                                                                     •Telephone:
   •City:                                                 •State:                                •Zip:


FORM ASHAR.INQ10/09.NC                                                                                                                               5-1
LIFE INSURANCE POLICY INFORMATION – PLEASE COMPLETE SEPARATE FORM FOR EACH POLICY:

  •Insurance Company:                                                                •Policy #:                                      •Issue Date:
  •Face Amount: $                                      •Total Policy Loan: $                                •Current Annual Premium: $
  •Total Premiums Paid $:                              •Next Premium Due:                                   •Current Cash Surrender Value: $
  •Maturity Age:                       •Policy Type:       Universal Life                Term           Survivorship           Whole Life           Variable Life
  •If survivorship policy, are both insured’s living?       Yes         No •If no, name of deceased insured?
  •Does the Policy have a Double Indemnity provision?              Yes         No
  •Does the policy have a Maturity Extension Rider?            Yes        No        •If yes, to what age?
  •Is this policy assigned?      Yes       No                                       • If yes, who is the assignee?
  •Has the policy or any of the policy premiums
                                                         •If yes, please answer the following: What Program?
  been financed by a third party?     Yes    No
  • Estimated loan payoff?                                                       • Maturity date of loan?
  •Policy Owner:                                                                 •Owner’s Social Security # or Tax ID:
  •Relationship to Insured:                              •Policy Owner’s Permanent Address:
  •City:                                                 •State:                                                   •Zip:
  •Policy Owner’s Marital Status:          Single       Married           Legally Separated             Divorced           Widowed
  •Has the Policy Owner ever declared bankruptcy?                 Yes       No                           •If yes, has it been discharged?       Yes      No
  •Date Discharged?                                      •Is the Policy Owner currently involved in a legal proceeding?                Yes    No
  •If policy is trust owned, full legal name of trust:
  •Situs of Trust:                                                               •Policy Beneficiary:
  •List all Trustees with Address and Phone Numbers:




PLEASE LIST OTHER INFORCE LIFE INSURANCE POLICIES ON INSURED:

   •Insurance Company:                                                                                         •Face Amount: $
   •Insurance Company:                                                                                         •Face Amount: $
   •Insurance Company:                                                                                         •Face Amount: $

PLEASE LIST OTHER INFORCE LIFE INSURANCE POLICIES ON 2ND INSURED:

   •Insurance Company:                                                                                         •Face Amount: $
   •Insurance Company:                                                                                         •Face Amount: $
   •Insurance Company:                                                                                         •Face Amount: $



  NAME OF PRIMARY INSURED                                SIGNATURE OF PRIMARY INSURED                                           DATE


  NAME OF SECONDARY INSURED                              SIGNATURE OF SECONDARY INSURED                                         DATE


  NAME OF POLICY OWNER                                   SIGNATURE OF POLICY OWNER                                              DATE


FORM ASHAR.INQ10/09.NC                                                                                                                                              5-2
         Suitability Verification for the Sale of Existing Life Insurance

         Please be advised that Ashar Group, LLC will not be able to exhaustively assist Policy Owner(s) and/or Insured(s) in determining the
    merits of selling their existing life insurance policy or policies based on their specific needs and situations without the disclosure of the
    financial related and personal information as requested below.

         Please check here if Policy Owner(s) chooses not to complete the information below and declines the assistance of the Ashar Group, LLC
    in determining suitability.


         Policy Owner’s Net Worth                                             $0 - $49,999
         (Please check one)                                                   $50,000 - $99,999
                                                                              $100,000 - $199,999
                                                                              $200,000 - $499,999
                                                                              $500,000 - $999,999
                                                                              $1,000,000 - $2,499,999
                                                                              $2,500,000 - $4,999,999
                                                                              $5,000,000 +


         Reason For Considering Sale                                          Planning to surrender or allow policy to lapse
         (Check ALL that apply)                                               No longer want or need coverage
                                                                              Premiums have become too costly
                                                                              Alternative to a 1035 exchange
                                                                              Seeking replacement policy
                                                                              Estate planning needs have been met
                                                                              Need cash liquidity for health & living expenses
                                                                              Interested in determining market value of policy
                                                                              Other (please describe):




         Verified and Confirmed By:




     PRINTED NAME                                        SIGNATURE OF POLICY OWNER                                               DATE



     PRINTED NAME                                        SIGNATURE OF POLICY OWNER #2 (if applicable)                            DATE



     PRINTED NAME                                        SIGNATURE OF PRIMARY INSURED (if different than above)                  DATE



     PRINTED NAME                                        SIGNATURE OF SECONDARY INSURED (if different than above)                DATE



     PRINTED NAME                                        SIGNATURE OF REFERRING ADVISOR (if applicable)                          DATE




FORM ASHAR.SUIT.INQ10/09.NC                                                                                                                         6-1
     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.


    1. Ashar Group, LLC and your referring advisor, if any, represents only you and shall act according to your instructions and
       in your best interest notwithstanding the manner in which Ashar Group, LLC and your referring advisor, if any, is
       compensated.

    2. 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. Ashar Group, LLC is not a tax advisor and recommends that you consult your own
       professional tax advisor regarding this transaction.

    3. The sale of your insurance policy may affect your right to receive Medicaid or other government benefits or entitlements.
       Advice on such effects should be obtained from the appropriate government agencies.

    4. Viatical/life settlement proceeds could be subject to the claims of creditors.

    5. There may be possible alternatives to selling your life insurance. This may include the option of an accelerated death
       benefit or policy loans offered by your life insurance company. You are advised to consult a financial advisor, certified
       public accountant and/or an attorney regarding these potential alternatives.

    6. Once you have received your proceeds from the sale of your life insurance policy, you will have ten (10) business days
       from receipt of the viatical/life settlement proceeds in which to rescind the transaction. If the insured dies during the
       rescission period, then the settlement contract shall be deemed rescinded, subject to repayment of all settlement
       proceeds.

    7. Funds will be sent to you within three (3) business days after the insurer or group administrator’s acknowledgment that
       ownership of the policy or interest in the certificate has been transferred and the beneficiary has been designated. Ashar
       Group, LLC and your referring advisor, if any, has no access to or control over viatical/life settlement provider funds that
       are set aside in escrow or trust.

    8. 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 or a certificate of a group life insurance policy to be
       forfeited; and 2) reduce the insured’s ability to obtain additional life insurance coverage in the future.

    9. Total compensation payable to Ashar Group, LLC and your referring advisor, 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 Purchase Price (GPP) as paid by the viatical/life settlement provider
       reduced by the total compensation as described above.

    10. All medical, financial or personal information solicited or obtained by a viatical/life settlement provider or Ashar Group,
        LLC about the insured, including the insured’s identity or the identity of family members, a spouse or significant other may
        be disclosed as necessary to effect the viatical/life settlement between you and the viatical/life settlement provider. If
        you are asked to provide this information, you will be asked to consent to this disclosure. The information may be
        presented 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 the policy owner’s and insured’s



FORM ASHAR.DISC.INQ12/09.NC                                                                                                        7-1
          identity and insured’s medical condition will 1) be shared with the insurer that issued the life insurance policy; and 2)
          shall be available to each subsequent owner of the life insurance policy.

     11. The insured may be contacted by the viatical/life settlement provider or Ashar Group, LLC or its authorized representative
         for the purpose of determining the insured’s health status. This contact will be limited to no more frequently than once
         every three (3) months if the insured has a life expectancy of more than one (1) year, and no more than once per month if
         the insured has a life expectancy of one (1) year or less.

     12. Ashar Group, 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.

     13. I/we confirm and acknowledge that Ashar Group, LLC has provided me/us with the a brochure developed and/or
         approved by the National Association of Insurance Commissioners (NAIC) describing the process of viatical/life
         settlements.

                         I/We acknowledge that I/we have read and understand the disclosures above (1-13)




       PRINTED NAME                                SIGNATURE OF PRIMARY INSURED                                 DATE




       PRINTED NAME                                SIGNATURE OF SECONDARY INSURED (if applicable)               DATE




       PRINTED NAME                                SIGNATURE OF POLICY OWNER #1 (if NOT Insured)                DATE




       PRINTED NAME                                SIGNATURE OF POLICY OWNER #2 (if NOT Insured)                DATE




       PRINTED NAME                                SIGNATURE OF AUTHORIZED REPRESENTATIVE OF ASHAR GROUP, LLC   DATE




FORM ASHAR.DISC.INQ12/09.NC                                                                                                       7-2
   PLEASE COMPLETE FOR EACH INSURED

    1.   Name of Insured:                                                                Date of Birth:                    Gender:        Male   Female
    2.   Insurance Company:                                                              Policy #:                         Policy Date:
         Death Benefit $:                                                         Premiums Paid to Date $:
    3.   Name of Initial Policy Owner (at time of Policy Issuance):
    4.   Name of Initial Beneficiaries (at time of Policy Issuance):
    5.   Name of Current Policy Owner (if different than question 3 above):
    6.   Name of Current Beneficiaries (if different than question 4 above):
    7.   What was the Insured’s and Policy Owner’s original purpose for buying the policy? Please explain in detail. Explanations such as “estate
         planning” should be expanded upon.




    8.   Before or at the time the policy was issued, did the Insured, Policy Owner or any other party arrange to transfer, sell, or assign, directly or
         indirectly the policy or any benefits to a third party?  Yes       No
         If yes, please describe the arrangement in detail and provide copies of any documents relating to the arrangement.



    9.   Has the Insured or Policy Owner ever assigned the policy or policy benefits to any person or entity?       Yes      No
         If yes, please describe the financing arrangement in detail and provide copies of any documents related to the arrangement.



    10. Has the policy or any of the policy premiums been financed by a third party, either through a loan, equity, contribution or otherwise?
             Yes       No
        If yes, please describe the financing arrangement in detail and provide copies of any documents related to the arrangement.


         If yes, what is the name of the lender?
         If yes, what is the principal loan amount?
         If yes, what is the loan maturity balance (payoff amount)?
         If yes, what is the loan maturity date?

    11. List all persons or entities (including any trust) who have, or have had any direct or indirect ownership or other interest in the policy or its
        proceeds, including the nature of the interest and the relationship of such person or entity to the Insured. For any entity, please identify
        all persons that own (or have owned) and, if different, control or manage (or have controlled or managed) that entity. For any trust,
        include all beneficiaries.
                                         c

         Name                            Nature of Interest                Date and Manner Interest was Obtained           Relationship to Insured


         Name                            Nature of Interest                Date and Manner Interest was Obtained           Relationship to Insured


         Name                            Nature of Interest                Date and Manner Interest was Obtained           Relationship to Insured



FORM ASHAR.CSQ.INQ10/09.NC                                                                                                                                 8-1
  12. Has the policy’s Beneficiary changed since the policy was issued?        Yes       No
       If yes, who was the Beneficiary at the time the policy was issued?
       If yes, what was their relationship to the Insured?
       If yes, why was the Beneficiary changed?
       If yes, who is the current Beneficiary and what is their relationship to the Insured?

  13. Has the Insured or Policy Owner borrowed money directly or indirectly in connection with the policy?       Yes      No
       If yes, please describe the borrowing arrangement in detail and provide copies of any documents relating to the arrangement.



  14. Are any of the interests of the Policy Owner in the policy pledged as security to any person or entity or otherwise encumbered or restricted
      in anyway?        Yes       No
  15. Prior to completing this application, has the Insured or Policy Owner ever given a person or entity the right or option to purchase the policy
      or a financial interest in the policy?     Yes      No
      If yes, please describe the option in detail and provide copies of any documents relating to that option.



  16. Does the Policy Owner or Insured have knowledge of any information that may be used by the issuing Insurance Carrier to challenge the
      payment of the policy’s death benefit, including whether the Policy Owner at the time of policy issuance had an insurable interest in the life
      of the Insured?     Yes      No
       If yes, please explain in detail:




 NEITHER ASHAR GROUP, LLC, NOR ANY REPRESENTATIVE OF ASHAR GROUP, LLC, IS OFFERING LEGAL OR TAX ADVICE IN CONNECTION WITH THE
 PROPOSED SALE OF THE LIFE INSURANCE POLICY DESCRIBED IN THIS DOCUMENT. EACH OF THE UNDERSIGNED HAS SOUGHT PERSONALIZED
 ASSISTANCE FROM AN ATTORNEY OR OTHER FINANCIAL PROFESSIONAL IN HIS/HER STATE OF RESIDENCE.

 Each of the undersigned Insured, Policy Owner, and Agent herby certify that the information provided in this questionnaire is true and correct as of
 the date hereof. Each of the undersigned affirms its understanding that Ashar Group, LLC and its affiliates will be relying on the statements and
 responses which are being provided by all of the undersigned in the questionnaire, and each of the undersigned agrees, jointly and severally to
 hold Ashar Group, LLC harmless and agrees to indemnify Ashar Group, LLC from and against any loss, liability, fees (including attorneys’ fees)
 costs, expense, claim or demand arising out of or in connection with any such statement or response.




 NAME OF PRIMARY INSURED                            SIGNATURE OF PRIMARY INSURED                                  DATE


 NAME OF SECONDARY INSURED (if applicable)          SIGNATURE OF SECONDARY INSURED (if applicable)                DATE


 NAME OF POLICY OWNER                               SIGNATURE OF POLICY OWNER                                     DATE


 NAME OF REFERRING ADVISOR                          SIGNATURE OF REFERRING ADVISOR                                DATE




FORM ASHAR.CSQ.INQ10/09.NC                                                                                                                             8-2
  PERSONAL DATA: (PLEASE COMPLETE FOR EACH INSURED)

    1.   Printed Name:                                                                                         DL/ID #:
    2.   Date of Birth:                                                            3.    Social Security #:
    4.   Height: ______ft. ______in.                           Weight: ________lb.                            5.    Gender:           Male      Female
    6.   Mother’s age, if living:___________ If deceased, age at death: ____________ Cause of death? ___________________________
         Father’s age, if living: ___________ If deceased, age at death: ____________ Cause of death? ___________________________
         Sibling’s age, if living: ___________ If deceased, age at death: ____________ Cause of death? ___________________________
         Sibling’s age, if living: ___________ If deceased, age at death: ____________ Cause of death? ___________________________
    7.   With whom do you reside?:
               Spouse          Relative               Child         Assisted Living Facility          Friend                Alone            Nursing Home
    8.   If living with “relative” or “friend”, how long have you been living with him/her?
    9.   If widowed, years since death of spouse:
    10. Are you currently employed?            Yes     No

         If yes, occupation:

    11. Have there been any major life changes in the last two(2) years? (Check all that apply)
                 Change of employment (include retirement, retirement for health reasons)
                 Loss of a family member or friend (include death, divorce and/or separation)
                 Change of residence
                 Other:

    12. If yes to any of these major changes, how long has it been since the event?


  LIFESTYLE:

    1.   Do you currently use tobacco in any form?            Yes   No      If yes, what type(s)?                                   Amount per day?
                 Cigarettes            Cigar          Pipe          Snuff          Chewing Tobacco                 Other
    2.   If no current tobacco use, have you ever used tobacco in the past and quit?            Yes     Never Used
         If yes, indicate type, amount used and when quit.
         Type?                                 Amount per day?                               How long ago did you quit?

    3.   Do you currently use Alcohol?          Yes     No                  If yes, what type(s)?                                   Amount per day?
    4.   If no current Alcohol use, have you ever used Alcohol in the past and quit?            Yes      Never Used
         If yes, indicate amount used and when quit?

         Type?                                 Amount per day?                               How long ago did you quit?

    5.   Do you participate in social activities outside the home?           Yes        No
                 Volunteer           Attend Social Events           Participate in Recreational Activities                 Travel            Play Cards
    6.   Do you have a pet?       Yes          No


FORM ASHAR.CLIENTASSESSMENT.INQ10/09.NC                                                                                                                     9-1
MEDICAL:

  1.   Have you ever consulted a doctor, been treated for and/or been diagnosed with any of the following conditions?
       (Please check all that apply)
              Arthritis                             Faintness/Fainting                  Amputation                   Bowel/Bladder Disorder
              Breathing Problem                     Broken Bone                         Cancer                       Chest Pain/Tightening
              Diabetes                              Digestive Problem                   Dizziness/Vertigo            Heart Attack
              High Blood Pressure                   Heart Disease                       Memory Loss                  Osteoporosis
              Seizures/Epilepsy                     Stroke/TIA                          Shortness of Breath          Vision Problems
              Weight loss                           Depression                          Difficulty hearing           HIV/AIDS
              Immune System Disorders               Liver Disease                       Kidney Disease               Hypertension
              TB/Lung Disorder                      Skin Disorder                       Ulcers                       Headaches
              Glaucoma                              Hepatitis _______(Type)             Cataracts                    Dementia
              Urinary infections                    Blood in stool                      Asthma
       Please provide details on the above checked conditions: (attach separate sheet if necessary)




  2.   Have you been told that you will need hospitalization, surgery, or nursing home care within the next 12 months?      Yes        No
       If yes, please describe:



  3.   Do you have a family history of any of the following? (Please check all that apply)
              Heart Disease            Depression          Diabetes          Cancer          Mental Illness   Dementia

  4.   What prescription medications do you take regularly? (List below and give doses)




  5.   Non-prescription medicines, alternative treatments, or herbal remedies? (List below and give doses)




FORM ASHAR.CLIENTASSESSMENT.INQ10/09.NC                                                                                                       9-2
FUNCTIONALITY:

  1.   Can you independently perform the following tasks? (Check all “yes” responses)
              Bathing                               Handling Finances                  Meal Planning                        Dressing
              Laundry                               Shopping                           Toileting                            Cooking
              Eating                                Take Medications                   Walking                              Using the Telephone
  2.   Do you use any device to assist you? (Check all that apply)
              Cane           Crutches               Wheelchair            Walker         Other:___________________________
  3.   Have you fallen or had any household accidents in past 2 years?     Yes      No
       If yes, please describe and indicate duration of time you were down on the ground/floor:




  4.   Do you currently drive?           Yes   No
       If yes, how often?        Daily         Weekly          Monthly

  5.   Did you fill out this questionnaire yourself?       Yes       No
       If no, Who helped you?




I certify that the information contained in this assessment is accurate and correct. I understand that the information I have provided will be used as the
basis for significant decisions, including financial decisions. Falsification of this assessment in any detail is grounds for disqualification from further
consideration and gives the purchaser and its agents and representatives the right to void any contract, settlement or other agreement based, in whole
or in part, on the information provided in this assessment.




 NAME OF INSURED                                        SIGNATURE OF INSURED                                              DATE



 NAME OF PERSON WHO COMPLETED THIS FORM                 SIGNATURE OF PERSON WHO COMPLETED THIS FORM                       DATE
 (IF OTHER THAN INSURED)                                (IF OTHER THAN INSURED)




FORM ASHAR.CLIENTASSESSMENT.INQ10/09.NC                                                                                                                   9-3
    Authorization for the Release of Life Insurance Policy Information (PLEASE COMPLETE FOR EACH POLICY)


     LIFE INSURANCE COMPANY                                                       POLICY NUMBER


     PRINTED NAME OF PRIMARY INSURED                                              PRINTED NAME OF SECONDARY INSURED (IF APPLICABLE)


     PRINTED NAME OF POLICY OWNER #1 (INCLUDING TRUSTEES)                         PRINTED NAME OF POLICY OWNER #2 (INCLUDING TRUSTEES)


     PRINTED NAME OF POLICY OWNER #3 (INCLUDING TRUSTEES)                         PRINTED NAME OF POLICY OWNER #4 (INCLUDING TRUSTEES)


    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,
    e-mail, telephonic or other request for information or documents required by Ashar Group, LLC and/or its affiliates, successors, assigns and
    authorized representatives (“Ashar Group, LLC”) relating to the above-referenced life insurance policy.

    I/we authorize the release of information by this form pertaining to the above-referenced life insurance policy to include but not be limited to
    the following:

        Original copy of the policy                                                   Verification of coverage
        Applications for insurance                                                    Change in ownership and beneficiary confirmation/designation
        Riders                                                                        Absolute or collateral assignment
        In-force illustrations, including projections of values in the future         Premium payments and payment provisions
        Conversions                                                                   Contestable and suicide status
        Withdrawals                                                                   Any and all other information
        Lapse or reinstatement status

    In addition, I/we authorize Ashar Group, LLC to share the information it receives from the life insurance company to any other person or
    entity, including the affiliates of each, required or compelled by law to receive or view such information to evaluate all of my/our options
    related to the above referenced policy. Ashar Group, LLC shall not release such information to any person or entity except as referenced
    above.

    I/we authorize and request that this Authorization shall remain valid until the death of the Insured (or if multiple Insureds, until the death of
    the last to survive), 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. I/we further authorize that a photocopy, PDF or electronic file or facsimile of this Authorization is
    as valid as an original.

    I/we certify that a) I/we am/are executing and delivering this Authorization freely and unilaterally/collectively as of the date written below;
    and b) I/we have a full understanding of the Authorization’s contents.

    Authorized By:

      PRINTED NAME                                          SIGNATURE OF PRIMARY INSURED                                          DATE


      PRINTED NAME                                          SIGNATURE OF SECONDARY INSURED (if applicable)                        DATE


      PRINTED NAME                                          SIGNATURE OF POLICY OWNER #1 (if NOT Insured)                         DATE


      PRINTED NAME                                          SIGNATURE OF POLICY OWNER #2 (if NOT Insured)                         DATE


      PRINTED NAME                                          SIGNATURE OF POLICY OWNER #3 (if NOT Insured)                         DATE


      PRINTED NAME                                          SIGNATURE OF POLICY OWNER #4 (if NOT Insured)                         DATE

FORM ASHAR.INSAUTH.INQ10/09.NC                                                                                                                      10-1
    Authorization for the Disclosure of Protected Health Information (PLEASE COMPLETE FOR EACH INSURED)
    I, _______________________________________ (the undersigned individual), 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, 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 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 Ashar
         Group, 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, monitor, facilitate, underwrite, solicit bids and/or complete 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 its 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 an Authorized Recipient to (1) 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; and (2) monitor, track or verify my health or medical status and condition in connection with any life insurance policy under
         which my life is insured that an Authorized Recipient, or any other person or entity, purchases. 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 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 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.
    Authorized by:

    PRINTED NAME                                          SIGNATURE OF INSURED                                                DATE


    PRINTED NAME                                          SIGNATURE OF LEGAL REPRESENTATIVE (if any)                          DATE
                DESCRIPTION OF LEGAL REPRESENTATIVE’S
                                    AUTHORITY (if any):
                                                          (POA, GUARDIAN AD LITEM OR SIMILAR STATUS–PLEASE ATTACH LEGAL DOCUMENTS FOR VERIFICATION)



FORM ASHAR.HIPAA.INQ10/09.NC                                                                                                                              11-1
        VIATICAL SETTLEMENTS




This guide is made available to assist North Carolina consumers with protecting their rights and making
informed decisions when considering the sale of their life insurance policies. Selling your life insurance
benefits terminates your beneficiary’s rights to claim future death benefits provided by your life insurance
policy, making this an extremely important individual decision. I believe you will find this guide to be
informative and helpful. I know it will help you make educated conclusions about your life insurance.

Your Department of Insurance is available to help guide you through these complicated matters. I want
every North Carolinian to know that help is available by calling our toll-free number, 1-800-546-5664.




                                                                   Wayne Goodwin,
                                                                   Commissioner of Insurance
What is a Viatical Settlement?

 A
            viatical settlement is a contractual             anticipated and timely death of the insured person.
            agreement to provide a life insurance            Viatical settlement investments are considered a type
            policyholder immediate cash in exchange          of security. The sale of investments involving viatical
 for the sale and transfer of life insurance policy          transactions are regulated by the North Carolina
 ownership rights. Generally, viatical settlements           Secretary of State’s Office (Securities Division). If
 appeal to insureds that are terminally ill and need         you have
 the cash settlement to pay for living and medical           questions
 expenses. However, viatical
 settlements may also be available to
 healthy insureds.
 Once the viatical settlement
 has been completed, the
 policyholder
 relinquishes
 ownership and
 control of the
 policy to the
 viatical provider,
 thus terminating
 the beneficiary’s
 right to collect
 the death benefit
 when the insured
 dies.
 From an investment perspective, a viatical settlement       concerning investments in viatical settlements, that
 is somewhat a speculative transaction involving the         office can be reached at 919-733-3924.


                                         Things to Consider Before Selling your Policy
   • Your existing life insurance policy may have cash         dishonest viatical settlement providers who
     value or other non-forfeiture benefits that might         might attempt to defraud you.
     be available to you.
                                                             • If transaction funds and executed agreements are
   • Selling (viaticating) your policy may create a            not properly escrowed, you may risk signing over
     taxable event resulting in tax consequences for           the ownership of your policy without receiving
     you or your estate.                                       any benefits.
   • Your future situation, circumstances and needs          • Life expectancy is an estimate of how long you
     may change.                                               may live. In actuality, you could live longer or
                                                               die sooner, regardless of your current state of
   • You may deny your surviving family members
                                                               health. Accordingly, you should consider both
     desperately needed life insurance benefits by
                                                               scenarios and consider how you and/or your
     viaticating your insurance policy.
                                                               beneficiary might be affected by a viatical
   • Beware of unlicensed, unscrupulous and                    settlement.


                                                         1
Who are the Parties Involved?

 K
           nowing the parties involved and                            negotiate a viatical settlement between a
           understanding industry terminology                         policyholder residing in North Carolina and a
           typically used in this type of financial                   viatical settlement provider.
 transaction may provide you with a better
                                                                    • An “escrow agent” acts as an independent
 understanding of viatical settlements.
                                                                      intermediary and is responsible for seeing that
     • A “viator” is the owner of an individual life                  both the viatical settlement provider and the
       insurance policy or a certificate holder under a               policyholder fulfill their obligations under the
       group policy who enters or seeks to enter into                 viatical settlement agreement. Once the escrow
       a viatical settlement contract.                                agent receives the full amount of payment
                                                                      from the provider and executed documents
     • The “insured” is the person on whose life an
                                                                      from the policyholder transferring ownership,
       insurance policy is written. Usually, the
                                                                      the transaction is finalized. The escrow agent
       insured is also the viator.
                                                                      cannot have any affiliation with the viatical
     • The viatical settlement provider, or “viatical                 broker or provider.
       provider,” is a company or individual that
                                                                Viatical providers and viatical brokers must be
       purchases the policy from the policyholder.
                                                                licensed to conduct business in North Carolina. To
       The viatical provider may sell beneficiary and
                                                                verify if a provider is licensed, contact the North
       ownership rights to investors.
                                                                Carolina Department of Insurance (NCDOI)
     • The viatical settlement broker, or “viatical             Consumer Services Division toll-free at 1-800-546-
       broker,” is a person or firm who represents the          5664. To verify if a broker is licensed, contact the
       policyholder and who offers or attempts to               NCDOI Agent Services Division at (919) 733-7487.


How Does the Process Work?

 T
         he process begins when the
         policyholder (and/or viatical broker)
         negotiates a price for the life
 insurance policy with the viatical provider.
 The negotiated price is usually represented as
 a percentage of the policy’s death benefit.
 The viatical provider then forwards
 settlement funds to the escrow agent and the
 policyholder forwards executed documents
 (transferring ownership of the policy to the viatical
 provider) to the escrow agent. When both parties               settlement offers than similar policies covering
 have satisfied all their obligations, the transaction is       healthy individuals.
 complete (i.e. the policyholder receives settlement
                                                                * Note: Once a policyholder receives settlement
 funds and the viatical settlement provider receives
                                                                funds, he or she has a “10-day free-look period” in
 ownership and control of the policy).
                                                                which to change his or her mind and cancel the
 Usually, life insurance policies covering individuals          settlement. The settlement funds must be returned
 with grave illnesses and shorter life expectancies can         to the viatical provider in order to cancel the viatical
 be expected to produce much larger viatical                    settlement under the free look provision.

                                                            2
                                                                        Accelerated Death Benefits

  B    efore considering a viatical settlement, a
       policyholder should check with his or her
  insurance company or agent to find out if the
                                                             While some older policies may not grant an
                                                             accelerated death benefit in the terms of the life
                                                             insurance contract, many companies are making
  policy qualifies for an accelerated death benefit.         this option available to their policyholders. A
  Sometimes referred to as “living benefits,” this           policyholder can check with his or her insurance
  policy provision provides life insurance benefits to       agent or company to find out if this option is
  insureds diagnosed with a terminal illness.                available.
  Depending on the contract, other qualifying                If you accept an accelerated benefit payment, you
  events may also trigger benefits, such as being            may become ineligible for Medicaid or other
  permanently confined to a nursing home or                  governmental benefits. Also, the benefits may be
  requiring an organ transplant. Qualifying events           taxable. We suggest that you consult with your
  can differ from contract to contract. The policy           tax and/or legal advisors to determine whether or
  may limit the amount that can be paid and any              not this may be the case in your individual
  amounts paid will generally reduce the death               situation prior to entering into any financial
  benefit payable to the beneficiary.                        agreement.




Viatical Settlement Tips
   • Shop around. Don’t be pressured into selling                 will have to pay the viatical provider that
     your policy for a lower value than you feel is               amount, PLUS the actual cash received if you
     appropriate.                                                 cancel the viatical contract during the “10-day
                                                                  free look” period.
   • A viatical transaction may require you to
     disclose confidential personal information                 • If the policy is a whole life policy, make sure
     including medical records to various                         you consider all policy values including
     individuals involved in the transaction.                     dividends, additional policy face value
                                                                  increases and accidental death, or other
   • Know who is involved in the transaction, and
                                                                  benefits, before signing and executing a viatical
     check them out thoroughly.
                                                                  settlement agreement.
   • Find out the name of the escrow agent used in
                                                                • Any funds received as part of a viatical
     the transaction and be sure you are confident
                                                                  settlement may be taxable and could change
     that he/she will act as an impartial party in the
                                                                  your current tax rate.
     transaction.
                                                                • Contact governmental agencies or charitable
   • Find out the name of the licensed viatical
                                                                  organizations that may provide benefits to you.
     provider involved in the transaction if you
                                                                  Income from a viatical settlement may
     negotiate through a viatical settlement broker.
                                                                  disqualify you from receiving Medicaid and/or
   • If there is an existing loan against your policy,            other benefits.
     you may have to pay it back before initiating a
                                                                • Obtaining a life insurance policy under false
     viatical settlement.
                                                                  pretense, for any purpose, is illegal. Anyone
   • Remember, if the viatical provider pays off a                engaged in such activities can face civil and
     policy loan out of the settlement proceeds, you              criminal charges.

                                                         3
                                                                             Required Disclosures

W        ith each viatical settlement application, the
         provider or broker must provide the viator
with the following disclosures no later than the
                                                                   rights and waiver of premium benefits that
                                                                   may exist under the policy, to be forfeited
                                                                   by the viator. Assistance should be sought
time the viatical settlement application is signed by              from a financial adviser.
all parties. These disclosures must be provided in a
                                                                8) Disclosure to a viator shall include
separate document that is signed by the viator and
                                                                   distribution of a brochure describing the
the provider or broker.
                                                                   process of viatical settlements.
    1) There are possible alternatives to contracts
                                                                9) The disclosure document must include the
       including any accelerated death benefits or
                                                                   following language: “All medical, financial
       policy loans offered under the viator’s
                                                                   or personal information solicited or
       policy.
                                                                   obtained by a provider or broker about an
    2) Some or all of the proceeds of the viatical                 insured, including the insured’s identity or
       settlement may be taxable under federal and                 the identity of family members, a spouse or
       state tax code. Assistance should be sought                 a significant other, may be disclosed as
       from a professional tax advisor.                            necessary to effect the viatical settlement
                                                                   between the viator and the provider. If you
    3) Proceeds of the viatical settlement could be
                                                                   are asked to provide this information, you
       subject to the claims of creditors.
                                                                   will be asked to consent to the disclosure.
    4) Receipt of the proceeds of a viatical                       The information may be provided to
       settlement may adversely affect the viator’s                someone who buys the policy or provides
       eligibility for Medicaid or other government                funds for the purchase. You may be asked to
       benefits or entitlements, and advice should                 renew your permission to share information
       be obtained from the appropriate                            every two years.”
       government agencies.
                                                                10) The insured may be contacted only by the
    5) The viator has the right to rescind a                        provider, broker or its authorized
       contract within 10 business days of                          representative for the purpose of
       receiving the viatical settlement proceeds. If               determining the insured’s health status.
       the insured dies during the rescission                       This contact is limited to once every three
       period, the settlement contract is rescinded                 months if the insured has a life expectancy
       subject to repayment of all viatical                         of more than one year and no more than
       settlement proceeds and any premiums,                        once per month if the insured has a life
       loans and loan interest to the provider or                   expectancy of one year or less.
       purchaser.
                                                             A provider must provide the viator with the
    6) Funds will be sent to the viator within three         following disclosures no later than the date the
       business days after the provider has received         contract is signed by all parties. These disclosures
       the insurer or group administrator’s                  must be conspicuously displayed in the contract or
       acknowledgment that ownership of the                  in a separate document signed by the viator and
       policy or interest in the certificate has been        the provider or broker:
       transferred and the beneficiary has been
                                                                1) The affiliation, if any, between the provider
       designated.
                                                                   and the issuer of the insurance policy to be
    7) Entering into a contract may cause other                    viaticated including the name, address and
       rights or benefits, including conversion                    telephone number of the provider.


                                                         4
       2) A broker shall disclose to a prospective                 4) The dollar amount of the current death
          viator the amount and method of                             benefit payable to the provider under the
          calculating the broker’s compensation. The                  policy. If known, the provider shall also
          term “compensation” includes anything of                    disclose the availability of any additional
          value paid or given to a broker for the                     guaranteed insurance benefits, the dollar
          placement of a policy.                                      amount of any accidental death and
                                                                      dismemberment benefits under the
       3) If an insurance policy to be viaticated has
                                                                      policy and the provider’s interest in those
          been issued as a joint policy or involves
                                                                      benefits.
          family riders or any coverage of a life other
          than the insured under the policy to be                  5) The name, business address and
          viaticated, the viator shall be informed of                 telephone number of the independent
          the possible loss of coverage on the other                  third-party escrow agent and the fact that
          lives under the policy and shall be advised                 the viator or owner may inspect or receive
          to consult with his or her insurance                        copies of the relevant escrow or trust
          producer or the insurer issuing the policy                  agreements or documents.
          for advice on the proposed viatical
          settlement.




Glossary
 Beneficiary – The person(s) designated to receive             policyowner in exchange for the policyowner’s
 the death benefit from a life insurance policy upon           (viator’s) assignment, transfer, and/or sale of all
 the death of the insured. In a viatical settlement, one       ownership rights in a life insurance policy.
 or more investors may receive this designation on an
 “irrevocable” basis (i.e. no one can change it                Viaticated Policy – A policy that has been acquired
 without written permission from the                                                          by a viatical
 beneficiary).                                                                                settlement provider
                                                                                               under a viatical
 Viatical Settlement Purchaser – A person who                                                       settlement
 invests in one or more viatical contracts.                                                              contract.
 Policyowner – The person or party who owns
 an insurance policy. The policyowner is
 usually the insured and/or the beneficiary,
 but can be someone else. The
 policyowner is the only person who
 can make changes to a policy.
 Viatical Settlement Contract –
 A written agreement
 establishing the terms
 under which
 compensation or
 anything of value will
 be paid to the

                                                           5
                         26
The Department of Insurance printed 5,000 copies of this publication a a cost of $1280.00 or $.256 per unit.
                                                                                     NCDOI 501 (June 02)

				
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