Fillable Application for Life Settlement Provider (California)

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Application for Life Settlement Provider (California)

On average this form takes 26 minutes to complete

The Application for Life Settlement Provider (California) form is 3 pages long and contains:

  • 2 signatures
  • 5 check-boxes
  • 95 other fields

Country of origin: US
File type: PDF

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I I
I I
I I
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State of California
Department of Insurance
Application for Life Settlement Provider
(Type or print clearly)
1. Life Settlement Provider Name:
2. FICTITIOUS NAMES:
A. Does the life settlement provider intend to use a fictitious (DBA) name?
Yes No
If yes, list such name: (This name must be approved by the Department prior to use.)
B. Is the life settlement provider now or has it ever used any name other than shown?
Yes No
If yes, list names, dates and reason(s) used.
3. LIFE SETTLEMENT PROVIDER TYPES: (check one only)
Corporation Limited Liability Partnership/Limited Partnership
General Partnership Individual Social Security Number (SSN)*: ___________________
Limited Liability Company
4. Federal Employer Identification Number 5. Incorporation /Formation date 6. State of Incorporation/Formation
7. Business Address (P.O. Box not acceptable.) 8. City 9. State 10. Zip Code
11. Business Phone Number 12. Business Fax Number 13. Business E-mail Address 14. Business Web Site Address
15. Mailing Address (P. O. Box is acceptable) 16. City 17. State 18. Zip Code
19. Contact Person for future correspondence from California Department of Insurance:
20. List the states in which Applicant is currently licensed as a Viatical or Life Settlement Provider:
(Attach a separate sheet if needed)
Type of License and License Number State Date License Held Is License In Force?
21. List the names of Applicant’s officers, directors, partners, and key management personnel and the job title of each person and a brief
description of the job duties. (Submit biographical affidavits and fingerprints on all such persons) (Attach a separate sheet if needed)
Name SSN*_ License #
Name SSN*_ License #
Name SSN*_ License #
Name SSN*_ License #
Name SSN*_ License #
Name SSN*_ License #
Name SSN*_ License #
Name SSN*_ License #
* Disclosure of your U. S. social security number is mandatory pursuant to Cal. Civil Code, § 1798.17; Cal. Family Code, § 17520(d); and Federal Privacy
Act of 1974, §§7(a) (2) (B) and 7(b). Your social security number will be used primarily for purposes of processing your application, including conducting any
necessary
investigation into your background. If you fail to disclose your social security number, your application will not be reviewed. An individual has a
right of access to certain records containing personal information pertaining to that individual. Individuals may obtain information regarding the location of
their records by contacting the Bureau Chief, Producer Licensing Bureau, California Department of Insurance by phone (800-967-9331) or by mail, to the
following address: 320 Capitol Mall, Sacramento CA 95814. Form LIC 441-19 (Rev 02/2014)
22. List the names of all entities and/or individuals of Applicant having an ownership interest of more than 10 percent of Applicant. Specify the corresponding
percentage of ownership for each named entity and/or individual. (Submit biographical affidavits and fingerprints on any individual).
Name___________________________________ Title_____________________
SSN/FEIN**________________
% of ownership_______
Name___________________________________ Title_____________________
SSN/FEIN**________________
% of ownership_______
Name___________________________________ Title_____________________
SSN/FEIN**________________
% of ownership_______
Name___________________________________ Title_____________________
SSN/FEIN**________________
% of ownership_______
23. Provide a copy of Applicant’s Articles of Incorporation or Partnership Agreement or any other applicable organizational document.
24.
If Applicant is not incorporated or organized in California, Applicant is required to provide:
(a)
A current certificate of good standing from Applicant’s state of domicile
(b)
A certificate of qualification from the California Secretary of State, or if Applicant is an LLC, a certificate of registration
(c)
Appointment of Agent for Service of Process, indicating the individual person designated as the Agent for Service of Process.
25.
Submit a detailed Plan of Operation that has been verified by an officer of the company who has knowledge of the facts set forth in the Plan. The
Plan of Operation should include the following:
(a)
Description of Applicant’s Marketing Plan, including how life settlements will be solicited and the targeted geographical area.
(b)
Detailed description of the corporate organizational structure of Applicant, including its parent company and all affiliates, along with an
organizational chart showing the ownership percentage of all affiliated companies up to the ultimate controlling person.
(c)
Detailed description of all criminal, civil, regulatory, and administrative action(s) taken against Applicant and/or Applicant’s ultimate controlling
parent by any governmental body (within the last ten (10) years), including all pending investigations of all such actions and all actions
outside of the United States, utilizing the following format:
Date: Show exact date of action
Responsible Government Body: Be specific, do not abbreviate. Include full name and address of agency, including zip code.
Case Number or Other Reference: Include both the agency and court case/reference number
Results of the Investigation or Action: Give a brief summary of results of the investigation or action
Pending approval or disapproval of application, if any investigation or action that was not mentioned in the initial Plan of Operation commences
against the Applicant, the Applicant must notify the Commissioner of such pending investigation or action.
(d)
Independent CPA Audited Financial Statements for the past three years, or until a profit (net income) is shown, whichever period is greater. If
Applicant has not yet completed three years of business, or has not yet shown a profit, then the Department requests Applicant to submit
projected financial information for the relevant period(s). The audited and pro forma (projected) financial statements must include detailed
assumptions, a balance sheet, income statement, and any SEC filings. The audited and pro forma (projected) financial statements must
cover the Applicant’s finances only; consolidated financial statements are unacceptable. All audited financial statements and pro forma
(projected) financial statements and all documents, materials, and communications and other written information submitted or received
pursuant to this subdivision shall be received in confidence within the meaning of Section 6254 of the Government Code and exempt from
disclosure pursuant to the Public Records Act (Chapter 3.5 (commencing with Section 6250) of Division 7 of Title 1 of the Government
Code.)
(e)
Detailed description of escrow procedures for life settlements; attach copy of escrow agreement/s.
(f)
Provide detailed description of procedures used by Applicant for protecting insured’s and policy owner’s sensitive medical and financial
information.
(g)
Applicant is required to submit a copy of Applicant’s life settlement contract forms to be used in California.
(h)
The following verification meets the requirements of California Code of Civil Procedure Section 2015.5 for execution of documents:
Title of Document: Plan of Operations
Date: _______________
VERIFICATION
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct and that I am authorized to
execute the same.
_______________ _________________________
Date Signature
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26.
APPLICANT’S CERTIFICATION:
Further, I certify under penalty of perjury that I have read the foregoing application and know the contents thereof and that each
statement therein is full, true and correct. I also certify under penalty of perjury that I have reviewed California Insurance Code,
section 10113.1 through 10113.3 and the Commissioner’s Life Settlement Regulations, codified at Title 10, Section 2548.1 et
seq. of the California Code of Regulations and thoroughly understand the business of life settlements and my obligations as a
life settlement provider. I understand that pursuant to sections 10113.1(g)(2)(D) and 10113.2(b) of the California Insurance Code, any
false statement may subject my application to denial and may subject my license/s to suspension or revocation.
SIGNATURE:
TITLE:
27.
DATE EXECUTED , AT ,
(month, day, year) (city)
(state)
Business Telephone Number
All fees are filing fees and are not refundable or transferable whether or not the application is acted upon or an examination taken.
**Disclosure of your U. S. social security number is mandatory pursuant to Cal. Civil Code, § 1798.17; Cal. Family Code, § 17520(d); and Federal Privacy
Act of 1974, §§7(a) (2) (B) and 7(b). Your social security number will be used primarily for purposes of processing your application, including conducting any
necessary investigation into your background. If you fail to disclose your social security number, your application will not be reviewed. An individual has a
right of access to certain records containing personal information pertaining to that individual. Individuals may obtain information regarding the location of
their
records by contacting the Bureau Chief, Producer Licensing Bureau, California Department of Insurance by phone (800-967-9331) or by mail, to the
following address: 320 Capitol Mall, Sacramento CA 95814. Form LIC 441-19 (Rev 02/2014)
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Application for Life Settlement Provider (California)

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Completed 8 March 2021

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