Fillable Life Settlement Application Form - For Maine Residents (Welcome Funds)

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Life Settlement Application Form - For Maine Residents (Welcome Funds)

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FORM WFI.WELCOME.EF1/16 © 2016 Welcome Funds Inc
WELCOME FUNDS INC.
4755 TECHNOLOGY WAY
SUITE 202
BOCA RATON, FL 33431
TOLL-FREE: 877.227.4484
PHONE: 561.862.0244
FAX: 561.862.0242
WWW.WELCOMEFUNDS.COM
A LETTER FROM THE FOUNDER
De
ar Policy Owner/Insured:
As Founder & CEO of Welcome Funds, I would personally like to thank you for considering our team to serve as your
personal representative in the secondary market for life insurance. We understand that you have choices in this process
and we appreciate the opportunity to represent you. We also know that selling your life insurance policy is an important
financial decision for you and your family, and our goal is to ensure that you are able to make this choice with confidence.
Welcome Funds is the one of the oldest and largest life settlement brokers in the United States and has assisted thousands
of Americans since our founding in 2000. As your broker, we work diligently to represent your best interests during the
entire transaction, from initial evaluation through the closing process. Our procedures consist of the following:
• Initial evaluation and review to determine eligibility;
• Evaluation Request assessment and processing;
• Medical records requests and life insurance policy verifications;
• Obtaining independent third party life expectancy report(s);
• Submission to authorized and/or state licensed secondary market buyers of life insurance policies;
• Best execution negotiations via an auction process in an effort to maximize the sales price of your policy;
• Closing services including contract review and assistance with closing contingency requirements.
In addition to the traditional procedure and lump sum cash settlements offered by the secondary market, we are also able to
provide alternative options that you may want to consider, depending on your personal needs:
1. Expedited Bid Process – for situations that require a fast turnaround time due to the possibility of a lapse or a
personal financial crisis;
2. Retained Death Benefit Offers – an offer to purchase the policy that includes a beneficiary of your choice
maintaining some death benefit, with the buyer paying all future premiums. This can include a combination of a cash
payout & retaining a portion of the death benefit. This option may not be available in all states or for all policies; or
3. Life Insurance Loans – if you are interested in a loan using your life insurance policy as collateral, we can also work
with multiple lending firms to secure financing. A loan option may not be available in all states or for all policies.
Please be sure to inform your advisor or your case manager if you would like to consider any of the above options. We
would also like to recommend that you discuss the tax consequences of selling your life insurance policy with a tax
advisor, as it is likely a taxable event, unless the insured qualifies for a viatical settlement or long-term care exemption in
compliance with IRS codes. Additionally, we have attached a brief brochure for your review issued by the Maine
Bureau of Insurance to provide an unbiased, independent description of selling policies in the secondary market.
As a reminder, you are under no obligation to sell your life insurance policy, in fact, if you need your coverage and can
afford to maintain it, we highly recommend that you do so!
Once again, thank you for allowing us the opportunity to help you reach your financial goals and to represent you in the
secondary market for the potential sale of your life insurance policy.
Sincerely,
John M. Welcom
Founder & CEO
FORM WFI.EF1/16 © 2016 Welcome Funds Inc
- 1 -
WELCOME FUNDS INC.
4755 TECHNOLOGY WAY
SUITE 202
BOCA RATON, FL 33431
TOLL-FREE: 877.227.4484
PHONE: 561.862.0244
FAX: 561.862.0242
WWW.WELCOMEFUNDS.COM
EVALUATION REQUEST FOR SALE OF EXISTING LIFE INSURANCE
This request is not an agreement to purchase your policy and you are under no obligation to sell your policy by completing this form.
The information that you provide in this request shall be used to evaluate and prepare your file, as required, to attempt to
negotiate and secure a conditional offer or offers for the potential sale of your existing life insurance policy.
PRIMARY INSURED’S INFORMATION
PRIMARY INSURED NAME (FULL LEGAL NAME) DATE OF BIRTH SOCIAL SECURITY NUMBER TELEPHONE NUMBER
CURRENT HOME ADDRESS CITY STATE ZIP CODE
PRIMARY ATTENDING PHYSICIAN SPECIALTY CITY/STATE DATE LAST SEEN TELEPHONE NUMBER
OTHER PHYSICIANS SEEN IN LAST 5 YEARS SPECIALTY CITY/STATE DATE LAST SEEN TELEPHONE NUMBER
OTHER PHYSICIANS SEEN IN LAST 5 YEARS SPECIALTY CITY/STATE DATE LAST SEEN TELEPHONE NUMBER
OTHER PHYSICIANS SEEN IN LAST 5 YEARS SPECIALTY CITY/STATE DATE LAST SEEN TELEPHONE NUMBER
HOSPITAL (S) NAME, ADDRESS, TELEPHONE NUMBER THAT HAS TREATED YOU IN THE LAST 24 MONTHS FOR YOUR ILLNESS
PLEASE PROVIDE A BRIEF DESCRIPTION OF YOUR MEDICAL HISTORY
Single
Married
Divorced
Widowed
PLEASE CHECK APPICABLE MARITAL STATUS IF MARRIED/DIVORCE/WIDOWED, PLEASE PROVIDE FULL NAME OF (EX)SPOUSE
SECONDARY INSURED’S INFORMATION
(If Applicable – 2
ND
To Die / Survivorship Policies Only)
SECONDARY INSURED NAME (FULL LEGAL NAME) DATE OF BIRTH SOCIAL SECURITY NUMBER TELEPHONE NUMBER
CURRENT HOME ADDRESS CITY STATE ZIP CODE
PRIMARY ATTENDING PHYSICIAN SPECIALTY CITY/STATE DATE LAST SEEN TELEPHONE NUMBER
OTHER PHYSICIANS SEEN IN LAST 5 YEARS SPECIALTY CITY/STATE DATE LAST SEEN TELEPHONE NUMBER
OTHER PHYSICIANS SEEN IN LAST 5 YEARS SPECIALTY CITY/STATE DATE LAST SEEN TELEPHONE NUMBER
OTHER PHYSICIANS SEEN IN LAST 5 YEARS SPECIALTY CITY/STATE DATE LAST SEEN TELEPHONE NUMBER
HOSPITAL (S) NAME, ADDRESS, TELEPHONE NUMBER THAT HAS TREATED YOU IN THE LAST 24 MONTHS FOR YOUR ILLNESS
PLEASE PROVIDE A BRIEF DESCRIPTION OF YOUR MEDICAL HISTORY
Family Member
Spouse
Business Partner
Other:________________________
PLEASE CHECK APPICABLE RELATIONSHIP TO PRIMARY INSURED (IF APPLICABLE)
If there are additional physicians or medical information, then please attach a separate sheet with complete details.
FORM WFI.EF1/16 © 2016 Welcome Funds Inc
- 2 -
LIFE INSURANCE POLICY INFORMATION
LIFE INSURANCE COMPANY FACE AMOUNT POLICY NUMBER ISSUE DATE
YES
NO
POLICY LOAN AMOUNT (IF ANY) ACCUMULATED/CASH VALUE (IF ANY) CASH SURRENDER VALUE (IF ANY) CASH VALUE USED TO PAY PREMIUMS?
Individual
Joint Survivorship
Group
Other: _____________________________________________
TYPE OF POLICY (PLEASE CHECK ONE)
IF A GROUP POLICY, PLEASE PROVIDE NAME, ADDRESS, AND TELEPHONE NUMBER OF THE CONTACT WITH THE ISSUING GROUP OR YOUR HR DEPT. CONTACT
Term
WL
UL
Other: _____________________________________________
CLASSIFICATION OF POLICY (PLEASE CHECK ONE)
Annually
Semi-Annually
Quarterly
Monthly $_______________________
POLICY PREMIUM PAYMENT (PLEASE CHECK THE APPROPRIATE BOX) PREMIUM AMOUNT
PLEASE PROVIDE NAMES AND RELATIONSHIP OF ALL PRIMARY BENEFICIARIES OF POLICY (IF IT IS A TRUST, PROVIDE TRUST NAME AND NAME & ADDRESS OF TRUSTEE(S))
ADDITIONAL BENEFICIARIES AND/OR CONTINGENT BENEFICIARIES
POLICY OWNER INFORMATION
If Individually Owned (if Insured is 100% Owner, skip to Bankruptcy Status):
LEGAL NAME OF POLICY OWNER # 1 RELATIONSHIP TO INSURED SOCIAL SECURITY NUMBER
POLICY OWNER # 1 ADDRESS CITY STATE ZIP CODE TELEPHONE NUMBER
LEGAL NAME OF POLICY OWNER # 2 (IF APPLICABLE) RELATIONSHIP TO INSURED SOCIAL SECURITY NUMBER
POLICY OWNER # 2 ADDRESS CITY STATE ZIP CODE TELEPHONE NUMBER
IF THERE ARE MORE INDIVIDUAL POLICY OWNERS, THEN PLEASE LIST ALL NAMES AND STATES OF RESIDENCE
Family Member
Spouse
Business Partner
Policy Owner is Insured
Other: ___________________
IF POLICY OWNER IS AN INDIVIDUAL, THEN PLEASE CHECK APPICABLE RELATIONSHIP TO INSURED
Single
Married
Widowed
Legally Separated
Divorced – Date: __________
IF POLICY OWNER IS AN INDIVIDUAL, THEN PLEASE CHECK MARITAL STATUS
YES
NO
YES
NO Date:______________________
HAS A POLICY OWNER EVER DECLARED BANKRUPTCY? IF SO, HAS IT BEEN DISCHARGED? (PLEASE PROVIDE ALL BANKRUPTCY DOCS) WHEN WAS IT DISCHARGED?
If Corporate or Trust Owned:
LEGAL NAME OF COMPANY OR TRUST RELATIONSHIP TO INSURED TAX ID NUMBER
COMPANY OR TRUST ADDRESS (OFFICIAL DOMICILE) CITY STATE ZIP CODE TELEPHONE NUMBER
LEGAL NAME OF AUTHORIZED COMPANY OFFICER OR TRUSTEE # 1 LEGAL NAME OF AUTHORIZED COMPANY OFFICER OR TRUSTEE # 2
TRUSTEE # 1 ADDRESS (IF DIFFERENT THAN TRUST) CITY STATE ZIP CODE TELEPHONE NUMBER
TRUSTEE # 2 ADDRESS (IF DIFFERENT THAN TRUST) CITY STATE ZIP CODE TELEPHONE NUMBER
For multiple policies, please reprint this page, then complete the above information and sign an insurance authorization form for each policy.
FORM WFI.EF1/16 © 2016 Welcome Funds Inc
- 3 -
ADDITIONAL INFORMATION
PLEASE PROVIDE REASONS FOR INTEREST IN SELLING POLICY(IES), CHECK ALL THAT APPLY:
Planning to lapse, cancel, or surrender the policy
Proceeds from sale will help pay for medical treatments
Health & living expenses are a financial burden
Considering a 1035 Exchange or replacement policy
Premium costs have become unaffordable
Cash liquidity preferred due to current financial situation
Original purpose of policy no longer exists
Higher estate tax exemptions has eliminated need for policy
Other or provide further details: _____________________________________________________________________________
PLEASE VERIFY LEGAL CAPACITY OF POLICY OWNER(S) & INSURED(S):
If you choose to accept a contingent offer as a result of this preliminary application process, each individual Policy Owner(s)
and Insured(s) may be required to have a Letter of Competency completed by an attending physician in order to verify their
legal capacity to enter into an agreement to sell the life insurance policy. If the legal capacity of any party is questionable, we
recommend obtaining an official Power of Attorney or Guardian ad Litem for that signatory as soon as possible.
Is there an existing Power of Attorney (POA) granting a legal representative the authority to act on behalf of a signatory or is there
a Guardian ad Litem or similar legal representative acting on their behalf regarding this Evaluation Request & Potential
Transaction?
Primary Insured: Yes No Policy Owner #1(if not insured): Yes No
Secondary Insured
(if applicable): Yes No Policy Owner #2 (if applicable): Yes No
If Yes, then please:
1) provide a full copy of the applicable legal documents (Durable POA or Medical POA) to verify the authority to sign on
behalf of the signatory;
2) have the legal representative sign all signature lines for that party; and
3) provide the names of such legal representative(s) below:
__________________________________________________ __________________________________________________
Name of Legal Representative of Primary Insured (if applicable) Name of Legal Representative of Policy Owner #1 (if applicable)
__________________________________________________ __________________________________________________
Name of Legal Representative of Secondary Insured (if applicable) Name of Legal Representative of Policy Owner #2 (if applicable)
PLEASE VERIFY SOURCE OF PREMIUM PAYMENTS AND/OR ASSIGNMENT OF POLICY:
1) Did the policy owner use a third-party to finance the premium payments? Yes No
If Yes, then please:
a) attach all loan documents, including contracts, trusts and/or corporate documents; and
b) provide the name of the lender/financing company: __________________________________________________
Name of Lender/Financing Company
2) Is the life insurance policy being used as collateral for a loan or is there a current lien or assignment recorded with the life
insurance carrier?
Ye
s
No
If Yes, please provide all loan documents & name of lienholder/assignee: __________________________________________
Name of Lienholder/Assignee
PLEASE VERIFY YOUR MARKET REPRESENTATION:
Are you working with any other third-party, other than Welcome Funds, related to the potential sale of your life insurance policy?
Yes No
If Yes, please check all that apply:
Financial Advisor
Life Agent
Attorney/CPA
Settlement Broker
Direct Buyer
Direct Lender
FORM WFI.EF1/16 © 2016 Welcome Funds Inc
- 4 -
PERSONAL ACKOWLEDGEMENTS
A. I/We represent that the information contained in this Evaluation Request for Sale of Existing Life Insurance is correct
and accurate and acknowledge that WELCOME FUNDS INC may rely on such information as my/our broker
for the potential sale of my/our life insurance policy. I/we also acknowledge that it is my/our responsibility
to notify WELCOME FUNDS INC of any changes to this information, including any changes in health of the insured
after this form has been submitted.
B. I/We understand that the market value of my/our life insurance policy is based in part on the health status and life
expectancy of the insured. Current medical records for the insured are vital to obtain life expectancy assessments. These
assessments are conducted by independent third-party life expectancy providers as required by the marketplace.
WELCOME FUNDS INC is not responsible for the conclusions of these life expectancy providers and does not have the
expertise to dispute those conclusions.
C. I/We acknowledge that WELCOME FUNDS INC is my/our broker who represents my/our best interests during the entire
transaction process. I/We also understand and acknowledge that WELCOME FUNDS INC issues no guarantee that an
offer will be secured for my/our policy.
D. I/We give my/our consent to WELCOME FUNDS INC, its agents and/or authorized representatives to release and/
or transmit electronically all financial, insurance, medical and personal information gathered from this Evaluation
Request for Sale of Existing Life Insurance, including but not limited to medical records, notes and lab reports
pertaining to the insured’s health, to the appropriate parties who have an identifiable need to review the information.
E. I/We acknowledge that this Evaluation Request for Sale of Existing Life Insurance may become part of my/our contract
for the sale of my/our existing life insurance policy if my/our policy is purchased. In addition, I/we have been advised
that I/we may obtain a copy, upon request, of any written agreement that I/we enter into regarding or relating to the sale
of my/our existing life insurance policy(ies).
F. I/We acknowledge that I/we have been provided the following address/department to direct any consumer complaints
that I/we may have: WELCOME FUNDS INC c/o Customer Complaints, to 4755 Technology Way – Suite 202, Boca
Raton, FL 33431.
G. I/We understand and acknowledge that WELCOME FUNDS INC does not provide any advice as to whether or not to
proceed with the sale of my/our life insurance policy and I/we are free to accept or decline any offer.
H. I/We understand and acknowledge that the policy owner is fully responsible for the timely payment of any and all
premiums due for the policy that is the subject of this potential transaction, on the applicable due dates, up until change
of ownership of the policy occurs, if a transaction is effectuated. I/We, not WELCOME FUNDS INC, assume sole
responsibility if the policy lapses for failure to make timely payment of any and all premiums.
I. I/We would like to consider the following options in addition to a lump sum cash settlement offer (subject to availability
based on state residency, policy types and qualification requirements):
Retained Death Benefit (RDB) Cash Settlement with RDB Life Insurance Loan/Credit Line
Expedited Bid Program (may require additional disclosures)
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.
I/We acknowledge that I/we have read and understand the information provided above.
___________________________________________ _________________________________ ________
Signature of Primary Insured Printed Name Date
___________________________________________ _________________________________ ________
Signature of Secondary Insured (if applicable) Printed Name Date
___________________________________________ _________________________________ ________
Signature of Policy Owner #1 (if not Insured) Printed Name Date
___________________________________________ _________________________________ ________
Signature of Policy Owner #2 (if applicable & if not Insured) Printed Name Date
FORM WFI.MEDISC.EF5/10 © 2010 Welcome Funds Inc
WELCOME FUNDS INC.
4755 TECHNOLOGY WAY
SUITE 202
BOCA RATON, FL 33431
TOLL-FREE: 877.227.4484
PHONE: 561.862.0244
FAX: 561.862.0242
WWW.WELCOMEFUNDS.COM
MAINE -- NOTICE OF DISCLOSURE
1. Welcome Funds Inc and your referring advisor/producer, if
any, represents only you and shall act according to your
instructions and in your best interest notwithstanding the
manner in which Welcome Funds Inc and your referring
advisor/producer, if any, is compensated.
2. Some or all of the proceeds of the settlement contract may be
free from federal income tax under the federal Health
Insurance Portability and Accountability Act of 1996, Public
Law 104-91; and restrictions, qualifications and other tax
laws, particularly those of the state in which you reside, may
apply. Some or all of the proceeds of the settlement contract
may be free from state income tax under Section 6809 (Maine
Law) and restrictions, qualifications and other tax laws,
including those of the state in which you reside, may apply.
Welcome Funds Inc 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. 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 thirty (30) calendar days
from the date of the settlement contract or fifteen (15)
calendar days from receipt of the proceeds, whichever is
earlier, in which to rescind the transaction as provided in
Section 6809 (Maine Law). Rescission, if exercised, is
effective only if both notice of the rescission is given and
repayment of all proceeds and any premiums, loans and loan
interest to the settlement provider is made within the
rescission period. If the insured dies during the rescission
period, then the contract shall be deemed rescinded, subject to
repayment being made to the settlement provider of all
proceeds and any premiums, loans and loan interest within the
rescission period.
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. WELCOME
FUNDS INC and your referring advisor/producer, if any, has no
access to or control over settlement provider funds that are set
aside in escrow or trust.
8. Entering into a 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 Welcome Funds Inc and your
referring advisor/producer, 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 settlement provider reduced by the total
compensation as described above. Actual compensation shall be
disclosed no later than the settlement contract is signed by all
parties.
10. All medical, financial or personal information solicited or
obtained by a settlement provider or Welcome Funds Inc 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 settlement contract between you and
the 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
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. Any person who knowingly presents false information in an
application for a settlement contract is guilty of a crime subject
to penalty, including fines and imprisonment.
12. Welcome Funds Inc recommends that you read the 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 Welcome Funds Inc has
provided me/us with a brochure developed by the Maine Bureau
of Insurance apprising consumers of their rights as owners of life
insurance policies.
I/We acknowledge that I/we have read and understand the disclosures above (1-13).
___________________________________________ _________________________________ ________
Signature of Primary Insured Printed Name Date
___________________________________________ _________________________________ ________
Signature of Secondary Insured (if applicable) Printed Name Date
___________________________________________ _________________________________ ________
Signature of Policy Owner #1 (if not Insured) Printed Name Date
___________________________________________ _________________________________ ________
Signature of Policy Owner #2 (if not Insured) Printed Name Date
FORM WFI.INSAUTH.EF1/16 © 2016 Welcome Funds Inc
WELCOME FUNDS INC.
4755 TECHNOLOGY WAY
SUITE 202
BOCA RATON, FL 33431
TOLL-FREE: 877.227.4484
PHONE: 561.862.0244
FAX: 561.862.0242
WWW.WELCOMEFUNDS.COM
AUTHORIZATION FOR THE RELEASE OF LIFE INSURANCE POLICY INFORMATION
_________________________________________ __________________________________________
Life Insurance Company Policy Number
_________________________________________ __________________________________________
Printed Name of All Policy Owner(s) Printed Name of Insured(s)
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, telephonic or other request for information or documents required by WELCOME FUNDS INC
and/or its authorized representatives pertaining to the above-referenced life insurance policy that I/we own.
I/
we understand and specifically authorize the release of information by this form to include any and all LIFE INSURANCE
POLICY OR CERTIFICATE information, including but not limited to: applications for insurance, forms, riders,
illustrations, conversions, current values, verification of coverage, contestable and suicide status, lapse or reinstatement
application and history and amendments concerning the policy or certificate, confirmation and status of change in ownership
designations and any other general information about my coverage.
WELCOME FUNDS INC makes it hereby known that the policy owner has the right to withdraw consent to this Release of
Life Insurance Policy Information at any time, pursuant to applicable law. I/we understand that WELCOME FUNDS INC
will keep all information disclosed hereunder confidential and will only use the information provided for the purpose of
evaluating my life insurance coverage, determining my eligibility for sale of my life insurance policy and facilitating the
potential sale of my life insurance policy. Furthermore, I/we understand that WELCOME FUNDS INC will not release any
information to any person or organization except as may be otherwise lawfully required or as I/we may further authorize.
I/we certify that I/we am/are executing and delivering this Authorization freely and unilaterally/collectively as of the date
written below. I/we further certify that I/we have a full understanding of the Authorization’s contents and I/we will retain a
completed copy for future reference. I/we specifically authorize and request that this Authorization for the Release of Life
Insurance Policy Information shall remain valid until the death of the Insured or until the case is declined by WELCOME
FUNDS INC, 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 and that a photocopy or facsimile of this document is as valid as an
original. This document may also be signed in counterparts.
Authorized By:
___________________________________________ _________________________________ ________
Signature of Policy Owner #1 Printed Name Date
___________________________________________ _________________________________ ________
Signature of Policy Owner #2 (if any) Printed Name Date
FORM WFI.HIPAA1.EF1/16 © 2016 Welcome Funds Inc
WELCOME FUNDS INC.
4755 TECHNOLOGY WAY
SUITE 202
BOCA RATON, FL 33431
TOLL-FREE: 877.227.4484
PHONE: 561.862.0244
FAX: 561.862.0242
WWW.WELCOMEFUNDS.COM
AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION
I, __________________________________ (the undersigned individual/primary insured), 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, laboratory, nurse, pharmacy, pharmacy
benefits manager, physician, physician practice group, insurance organization and any other type of health care provider (each, an
“Authorized 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 WELCOME FUNDS INC including a) 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 b) to any other
person or entity required or compelled by law to receive or view such PHI to evaluate, facilitate, underwrite and solicit bids for the
sale of my life insurance policy(ies), including but not limited to medical underwriters, lenders, financing entities, buyers of life
insurance policies, life expectancy providers and stop-loss re-insurers and his or their affiliates, agents, subsidiaries, corporate
parents, independent contractors, consultants, service providers 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 the Authorized Recipient to a) evaluate and/or underwrite my health status or life
expectancy; and/or b) monitor, track or verify my health status in connection with any life insurance policy under which my life is
insured that an Authorized Recipient, or any other person or entity, purchases. I hereby authorize the disclosure of my health
information as described above. I understand the information disclosed may include information relating to Acquired
Immunodeficiency Syndrome (AIDS), Human Immunodeficiency Virus (HIV), sexually transmitted diseases, psychiatric care,
mental health services, genetic testing, and/or treatment for alcohol and drug abuse.
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
Authorized 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.
____________________________________________________________________________________________
List of Authorized Disclosers (AD) (Hospitals, Doctors, Etc.):
‘
Authorized by:
___________________________________________ _________________________________ ________
Signature of Individual (Primary Insured) Printed Name Date
___________________________________________ _________________________________ ________
Signature of Legal Representative of Primary Insured (if any) Printed Name Date
Description of Legal Representative’s Authority (if any): _______________________________________________________________________________________________
(POA, Guardian ad Litem or similar status – Please attach legal documents for verification)
FORM WFI.HIPAA2.EF1/16 © 2016 Welcome Funds Inc
WELCOME FUNDS INC.
4755 TECHNOLOGY WAY
SUITE 202
BOCA RATON, FL 33431
TOLL-FREE: 877.227.4484
PHONE: 561.862.0244
FAX: 561.862.0242
WWW.WELCOMEFUNDS.COM
AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION
I, __________________________________ (the undersigned individual/second insured), 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, laboratory, nurse, pharmacy, pharmacy
benefits manager, physician, physician practice group, insurance organization and any other type of health care provider (each, an
“Authorized 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 WELCOME FUNDS INC including a) 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 b) to any other
person or entity required or compelled by law to receive or view such PHI to evaluate, facilitate, underwrite and solicit bids for the
sale of my life insurance policy(ies), including but not limited to medical underwriters, lenders, financing entities, buyers of life
insurance policies, life expectancy providers and stop-loss re-insurers and his or their affiliates, agents, subsidiaries, corporate
parents, independent contractors, consultants, service providers 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 the Authorized Recipient to a) evaluate and/or underwrite my health status or life
expectancy; and/or b) monitor, track or verify my health status in connection with any life insurance policy under which my life is
insured that an Authorized Recipient, or any other person or entity, purchases. I hereby authorize the disclosure of my health
information as described above. I understand the information disclosed may include information relating to Acquired
Immunodeficiency Syndrome (AIDS), Human Immunodeficiency Virus (HIV), sexually transmitted diseases, psychiatric care,
mental health services, genetic testing, and/or treatment for alcohol and drug abuse.
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
Authorized 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.
____________________________________________________________________________________________
List of Authorized Disclosers (AD) (Hospitals, Doctors, Etc.):
‘
Authorized by:
_________________________________ ________ ___________________________________________
Signature of Individual (Second Insured)
Printed Name Date
_________________________________ ________ ___________________________________________
Signature of Legal Representative of Second Insured (if any)
Printed Name Date
Description of Legal Representative’s Authority (if any): _______________________________________________________________________________________________
(POA, Guardian ad Litem or similar status – Please attach legal documents for verification)
I
mportant information about your life insurance policy
Prepared by the Maine Bureau of Insurance
Life insurance is a critical part of a broader financial plan. There are many options
available, and you have the right to shop around and seek advice from different financial
advisers in order to find the option best suited to your needs.
You are encouraged to consider the following possible alternatives to requesting a surrender of
your life insurance policy, requesting accelerated death benefits under your life insurance policy,
or letting your life insurance policy lapse. These alternatives include, but are not limited to:
• Accelerated Death Benefit: Your policy may provide an early or accelerated discounted
benefit payment if you have a terminal or chronic illness.
• Cash Surrender: Your policy may have a cash surrender value your life insurer would
pay you if you cancel it.
• Gift: You may be able to give your policy to your beneficiary, who would then assume
responsibility for paying premiums.
• Life Settlement: You may be able to sell your life insurance policy to a third party for an
amount greater than the cash surrender value or accelerated death benefits under your
policy. You pay no further premium. The third party becomes the policyholder and
receives the benefit upon the insured’s death.
• Maintain Your Policy: You may be able to maintain your life insurance policy in force
by paying the premiums directly or using your current policy values to pay the premiums.
• Policy Changes: You may be able to reduce or eliminate future premium payments by
obtaining a paid-up policy, by reducing optional coverages, or through other options
available from your life insurer.
• Policy Loan: You may be able to take out a loan from your life insurance company using
the cash value of your policy as collateral. Loan proceeds can be used to pay the
premiums or for other purposes.
• Third-Party Loan: You may be able to get a loan from another party to pay your
policy’s premiums. In return, the lender may require an assignment of a portion or all of
the policy’s death benefits.
– 2 –
These options may or may not be available depending on your circumstances and the terms of
your life insurance policy. Please see your policy or contact your life insurance company,
financial adviser, agent, or broker to determine your particular options.
IMPORTANT INFORMATION: Maine law requires life settlement brokers to have a proper
license. If you are approached to sell your policy or if you are looking to sell your policy, please
check with the Maine Bureau of Insurance for a list of licensed life insurance producers.
If you are a Maine resident and have questions about life insurance and your rights, contact the
Maine Bureau of Insurance at 1-800-300-5000, or go to www.maine.gov/pfr/insurance
. Ask
questions if you don’t understand your policy.
COMMONLY USED TERMS
Accelerated death benefit: A benefit allowing terminally ill or chronically ill life insurance
policyholders to receive cash advances of all or part of the expected death benefit. The
accelerated death benefit can be used for health care treatments or any other purpose.
Cash surrender value: This term is also called “cash value,” “surrender value,” and
“policyholder’s equity.” The amount of cash due to a policyholder who cancels his or her life
insurance policy before it matures or death occurs.
Expected death benefit: The amount that the insurance company would pay the beneficiaries
named in the life insurance policy if the insured died today.
Face amount: The death benefit the insurer is required to pay the beneficiaries named in the life
insurance policy upon the death of the insured, as stated in the policy. The actual death benefit
may differ due to such factors as policy loans, failure to pay premiums, and for some types of
policies, investment performance.
Lapse: Refers to a life insurance policy ending or expiring when a policyholder stops making
premium payments.
Life settlement: A contract in which the policyholder sells his or her life insurance policy to a
third party for a payment that is less than the expected death benefit of the policy. Life
settlements include viatical settlements, defined below.
Policy loan: A loan issued by an insurance company using the cash value of a person’s life
insurance policy as collateral.
Viatical settlement: An arrangement in which someone with a terminal illness sells his or her
life insurance policy at an amount less than the death benefit. The ill person receives cash, and
the buyer receives the full amount of the death benefit. This death benefit is payable once the
former policyholder dies.
This brochure is for informational purposes only and does not constitute an endorsement of any
of the options described above.
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Life Settlement Application Form - For Maine Residents (Welcome Funds)

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Completed 26 June 2021

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