9. All medical, financial, or personal information solicited or obtained by a provider or
broker about an insured, including the insured’s identity or the identity of family
members, a spouse, or a significant other may be disclosed as necessary to effect the
life settlement contract between the owner and provider. If you are asked to provide this
information, you will be asked to consent to the disclosure. The information may be
provided to someone who buys the policy or provides funds for the purchase. You may
be asked to renew your permission to share information every two (2) years.
10. The insured may be contacted by either the provider or the broker or its authorized
representative for the purpose of determining the insured’s health status or to verify the
insured’s address. This contact is limited to 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.
11. The broker represents the owner, exclusively, and not the insurer or the provider or any
other person, and owes a fiduciary duty to the owner, including a duty to act at any times
according to the owners’ instructions and in the best interest of the owner.
12. The name, business address, and telephone number of the life settlement broker are as
(brokers’ printed name)
13. The following affiliation(s) or contractual relation(s) exists between the provider and the
14. The following affiliation(s) or contractual relation(s) exists between the provider and with
the issuer of the policy to be settled: ________________________________________.
LIFE INSURANCE POLICY OWNER’S ACKNOWLEDGMENT: I have read and fully
understand this disclosure form. I have received a copy of this disclosure to keep for
LIFE INSURANCE POLICY OWNER LIFE SETTLEMENT PROVIDER OR BROKER
By: _____________________________ By: _____________________________
Printed Name: ____________________ Printed Name: ____________________
Date: ___________________________ Date: ___________________________