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e. List the total number (nationwide) of life
insurance policies settled involving a retained
beneficiary during the immediately preceding
calendar year: _________________________
f. List the aggregate face amount (nationwide) for
policies settled involving a retained beneficiary
during the immediately preceding calendar year:
$______________________________________
g. List the aggregate premium commitment h. List the total number of life insurance policies
(nationwide) for policies settled involving a settled in California involving a retained
retained beneficiary during the immediately beneficiary during the immediately preceding
preceding calendar year: $__________________ calendar year: ___________________________
i. List the aggregate face amount for policies settled j. List the aggregate premium commitment for
with respect to California residents involving a policies settled with respect to California
retained beneficiary during the preceding calendar residents involving a retained beneficiary during
year: $___________________________________ the preceding calendar year: $_______________
6. Is the provider submitting its audited financial statement with annual statement?
If NO, please ensure an audited financial statement is provided in accordance with
Section 2548.15.
Yes No
7. GENERAL INTERROGATORIES
a. Has there been any change in the provider’s name, organizational structure or status,
Charter, Articles of Incorporation, Bylaws, Partnership Agreement, affiliations,
officers, directors, members, owners, stockholders or location of books and records
since the date of the application or the last Annual statement was filed with the
Department?(Note: Any provider transferring more than 10% of its stock or
ownership to an unlicensed provider is barred from settling policies within this state
until the Commissioner approves a new life settlement application whenever the
provider is either organized within this state or conducting at least 5% of its business
within the state.)
Yes No
(i) If there has been a change, has complete documentation been filed with the
Department (i.e. amendments, biographical affidavits, fingerprint cards)?
Yes No
NA
(ii) If there has been a change and complete documentation was not provided to the
Department, attach a complete documentation.
b. Has any officer, director, member, stockholder, or employee of the provider been the
subject of any administrative or judicial proceeding, had any license denied,
suspended or revoked, been arrested, indicted, convicted, or pled nolo contendere to
any criminal or civil action other than a minor traffic violation, or had a lien,
judgment or foreclosure action filed against him or her since the date of application
or the last Annual Statement was filed with the Department?
If so, attach a detailed explanation sufficient to disclose all relevant details of the
matter, to include its final disposition.
Yes No
