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Value City Bankrupt

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                                                       Application for Life Settlement

Program:


What Settlement Program are you applying for?:            Traditional                     Small Face Value (Powered by Cielo)
                                                               (Select any or all that apply)


Insured Information:

Insured Name:

SSN:                                          Date of Birth:                                               Sex:

Address:

City:                                         State:                                     Zip Code:                  Country:

Phone Number:                                 Email Address:


Marital Status:          Married         Single           Widowed                 Divorced


Have you ever been party to a bankruptcy?:          Yes            No



Second Insured Information:
Medical Information:

Physician Name:

Address:

City:                                         State:                                     Zip Code:

Phone Number:                                             Fax Number:

List any other specialists:




           Berkshire Settlements, Inc. - 3350 Riverwood Parkway, Suite 2270 Atlanta, GA 30339 - (678) 589-9950 [O] - (678) 589-9951 [F]
                                                       Application for Life Settlement

Second Insured Information (If Applicable):

Insured Name:

SSN:                                          Date of Birth:                                         Sex:

Address:

City:                                         State:                            Zip Code:                     Country:

Phone Number:                                 Email Address:


Marital Status:          Married         Single           Widowed          Divorced


Have you ever been party to a bankruptcy?:          Yes        No



Second Insured Medical Information (If Applicable):

Physician Name:

Address:

City:                                         State:                            Zip Code:

Phone Number:                                             Fax Number:

List any other specialists:




           Berkshire Settlements, Inc. - 3350 Riverwood Parkway, Suite 2270 Atlanta, GA 30339 - (678) 589-9950 [O] - (678) 589-9951 [F]
                                                         Application for Life Settlement

Life Insurance Policy Information:

Insurance Company:                                                                                Policy Number:

Issue Date:                                           Issue State:                                Death Benefit:

Premium Amount:                                       Last Premium Paid Date:                         Next Premium Due Date:

Mode:          Monthly           Quarterly             Semi-Annually           Annually

Loan Amount:                                    Accumulated Value:                                Cash Value:

Policy Type:        Universal              Variable        Whole            Term (Convertible)         Term (Non-Convertible)         Other


Policy Plan:        Individual        Survivor           Group         Other


Has the policy ever lapsed?          Yes         No       Reason for sale of the policy:


Was the policy premium financed?               Yes         No        If yes, through which program?


What is the reason for the sale of the policy?


Beneficiary Information:

Beneficiary Name:

Address:

City:                                           State:                             Zip Code:                       Date of Birth:

Phone Number:                                               Fax Number:

List any other Beneficiaries and their state or residence:




           Berkshire Settlements, Inc. - 3350 Riverwood Parkway, Suite 2270 Atlanta, GA 30339 - (678) 589-9950 [O] - (678) 589-9951 [F]
                                                       Application for Life Settlement

Life Insurance Policy Owner Information:

Owner Type:            Insured        Other Individual         Trust        Corporation          Other           Unknown


Owner Name:                                                                                     Tax ID:

Address:

City:                                         State:                            Zip Code:                     Country:

Phone Number:                                 Email Address:

Relation to Insured:       Family         Friend         Professional            Other

If more than one owner name, please the names below (attach more sheets if necessary):




Representing Agent Information:

Company Name:                                                                                     Tax ID:

Contact Person(s):

Address:

City:                                         State:                            Zip Code:

Phone Number:                                            Fax Number:


If required, is the representing agent licensed in the state where the policy is domiciled?         Yes        No

Is the representing agent the writing agent of the policy?                                          Yes        No




           Berkshire Settlements, Inc. - 3350 Riverwood Parkway, Suite 2270 Atlanta, GA 30339 - (678) 589-9950 [O] - (678) 589-9951 [F]
                                                      Application for Life Settlement

Fraud Warning:

   ANY PERSON WHO KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE OR AN APPLICATION FOR A
    LIFE SETTLEMENT CONTRACT MAY BE CHARGED WITH A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON.


Consent to Contact Insured:
  By signing this application the individuals identified as "Insureds" are consenting to allow Berkshire or its Authorized Representatives
  or Strategic Partners to contact the insured directly to conduct an interview in regards to their medical history. This point of contact
  with the insured will only be to discuss their medical history and no insurance related or information in reference to the life
  settlement that is being applied for will be discussed with the potential viator. (ONLY APPLIES TO SETTLEMENTS POWERED BY CIELO)

Statement of Mental Competency:
  By signing this application the individuals identified as "Owner" and "Insured" represents and warrants that they are of sound mind at
  the time of applying for a potential life settlement with Berkshire Settlements, Inc., that the owner and insured (if different)
  understand the financial transaction that is being proposed to them and are of the mental capacity to complete the transaction. If
  the owner and insured decide to sell their policy through Berkshire Settlements, Inc. they will be required to have a physician verify
  their mental competency at the time of sale.


Signatures of Owner & Insured:


    Signature of Owner                                                             Signature of Insured:



    Printed Name of Owner                                                          Printed Name of Insured:



    Date:                                                                          Date:




Signatures of Second Owner & Insured (If Applicable):



    Signature of Owner                                                             Signature of Insured:



    Printed Name of Owner                                                          Printed Name of Insured:



    Date:                                                                          Date:




            Berkshire Settlements, Inc. - 3350 Riverwood Parkway, Suite 2270 Atlanta, GA 30339 - (678) 589-9950 [O] - (678) 589-9951 [F]

				
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