VIATICAL AND LIFE SETTLEMENT APPLICATION PACKAGE
To expedite policy sale, please complete the following application and return it with all items on this checklist.
The application information will be forwarded to viatical and life settlement providers. Please call
(314.997.9203) or email Edmund R. Whitelaw to review any questions.
1. A separate application is needed for each policy. Each application must be filled out completely, signed
and witnessed. Mark “N/A” whenever applicable.
2. A photocopy of the insured’s Social Security card must accompany the HIPAA Release.
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3. 5 years of medical records from attending physicians, current within 30 days of application. However, if
the insured requests and Edmund R. Whitelaw agrees to obtain this information, the insured must forward
the ‘Insured Letter to Physician’ (see page 9) to each physician listed on page 6 and enclose letter copies.
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4. Exclusive Broker of Record Letter must be signed, dated and witnessed. (Note: If any providers are to be
excluded from this Exclusive Broker of Record authorization, their name and exclusion reason should be
separately explained.)
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5. Insured’s Photo ID must be current and cannot be expired. Accepted forms of identification are
photocopies of a current driver’s license or passport.
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6. Complete copy of the life insurance policy including agent application and medical exam information. If the
policy cannot be located, please contact the carrier and request a replacement. Upon receipt, the
replacement or a scanned copy should be forward.
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7. Copy of current policy values and an inforce reillustration showing the annual premium required to sustain
the policy to its contract maturity unless Life Settlement Partners agrees to obtain this information.
8. If owner/beneficiary is a trust, we need:
Copy of trust agreement and Tax ID Number
Confirmation of State of Trust Situs
Trustee(s) must sign the policy information release form
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9. If owner/beneficiary is a corporation, we need:
Complete name and address of corporation, and Tax ID Number.
Corporate resolution showing current authorized officers.
Two officers must sign the policy information release form.
10. If the beneficiary is an individual, we need name, address and Social Security number information along
with a Photo ID.
FRAUD WARNING
ANY PERSON WHO KNOWLINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE OR AN
APPLICATION FOR A LIFE SETTLEMENT CONTRACT IS GUILTY OF CRIME AND MAY BE SUBJECT TO FINES AND
CONFINEMENT IN PRISION.
1
INSURED INFORMATION
First Insured Name: ___________________________________________ Social Security #: ______ ______ ______
Street Address: (No PO Box) _________________________________________________________________________
City: ____________________________ State: ________ Zip Code: ________ Home Phone: ______________________
Date of Birth: ________ /________ /________ Gender: Female
Male
Citizenship: US
Other
Second Insured Name: _________________________________________ Social Security #: ______ ______ ______
Street Address: (No PO Box) _________________________________________________________________________
City: ____________________________ State: ________ Zip Code: ________ Home Phone: ______________________
Date of Birth: ____ /____ /_______ Female
Male
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Marital Status: _____________Citizenship: US
Other
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LIFE INSURANCE POLICY INFORMATION (provide for each policy being offered for sale)
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Name of Insurance Company: ______________________________ Policy Number: __________________________
Face Value: $___________________________ Policy Issue Date: __________________
Cash Surrender Value $________________________ Outstanding Loan Amount $________________
Insuring: Individual
Survivorship
Policy Type: Universal
VUL
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Term
Whole Life
Group
If Term, can the policy be converted and, if so, until what date? _________________________
Annual Premium _____________ Paid: A
Policy Premium Financed: Yes
No
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Next premium due date_________________
Finance Company: ____________________________________________
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SELLER INFORMATION
Q
Policy Owner: ____________________________________________________________________________________
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Current Address: __________________________________________________________________________________
SS or Tax ID # _____________________ Phone: ______________________ Fax: _____________________
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If Trust or Corporation, names of Trustee(s) or 2 officers: __________________ _______________________________
________________________________________________________________________________________________
Beneficiary (ies): __________________________________________________________________________________
If an individual, Social Security #: ______ ______ ______
Address (es): ______________________________________________________________________________________
Since this policy has been in force, has owner been a party to a: [check all that apply]
Civil Suit
Bankruptcy
Judgments
Creditor Liens
Tax Liens
Divorce
Explain any checked answers on a separate page and attach all discharge papers.
2
SETTLEMENT INFORMATION
Reason for original purchase: Estate Planning
Family Protection
Buy sell agreement
Other ______________
Reason for selling: _________________________________________________________________________________
Has an application for insurance on insured’s life/health ever been declined, rated or modified in any way
(including this policy)? Yes
No
If yes, give company and reason: ______________________________
__________________________________________________________________________________________________
Does the insured plan to purchase new life insurance? ____________________________________________
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Total face value of life insurance NOT being offered for sale herewith ____________________________________
Has the policy been previously marketed for secondary market sale? Yes
period and reason policy was not sold.
No
Has the policy or any of the policy premiums been financed by a third party? Yes
Information Questionnaire.
If yes, provide broker name, time
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If yes, complete the
Has the insured or policyowner ever assigned the policy or policy benefits to any person or entity? Yes
complete the Information Questionnaire.
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Has the name of the policy owner or beneficiaries changed since the time of policy issuance? Yes
complete the Information Questionnaire.
No
No
If yes,
If yes,
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MEDICAL – See Separate Form
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PERSONAL ACKNOWLEDGEMENT
I represent and warrant that the information contained in this application is correct and accurate and that I will
immediately notify Edmund R. Whitelaw of any changes in this information. I further give my consent to Edmund R.
Whitelaw to release this application and all information gathered while processing it as necessary for the sole purpose of
soliciting the purchase of my life insurance policy. I acknowledge I may be contacted by Edmund R. Whitelaw regarding
the information contained in this application.
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I acknowledge that I am submitting this application for Edmund R. Whitelaw to evaluate the purchase of my life
insurance policy and that Edmund R. Whitelaw has made no representation or guaranty that my policy will be sold. I
acknowledge that Edmund R. Whitelaw is not responsible for any failure on the part of a potential buyer to purchase my
policy on terms offered by a potential buyer through Edmund R. Whitelaw.
I acknowledge that I have determined the relative benefit of a life settlement transaction after review of the
transaction’s legal and financial implications with my attorney, accountant or other appropriate advisor. I also
acknowledge that Edmund R. Whitelaw has not made any representations or provided any advice concerning the
possible tax consequences or treatment of the proceeds of this transaction.
Policy Owner Signature: ________________________Printed Name _____________________ Date: _______________
Witness Signature: ____________________________ Printed Name ______________________ Date: ______________
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VIATICAL AND LIFE SETTLEMENT APPLICATION DISCLOSURE STATEMENT
1. There are alternatives to the process of selling your policy that may be preferable such as accelerated benefits,
borrowing against the policy, and surrendering the policy. Also, policy provisions for double or additional indemnity
for accidental death, or riders or other provisions insuring the lives of a spouse, dependents or others may be lost
upon sale of your policy. Information on these alternatives and provisions should be obtained from the Insurer that
issued the policy.
2. Some or all of the proceeds of your settlement may be taxable under federal income tax and/or state franchise and
income tax laws. Also, proceeds from a settlement may not be exempt from claims of creditors, personal
representatives, trustees in bankruptcy and receivers in state or federal court. Advice concerning possible
consequences should be obtained from your attorney and/or tax advisor.
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3. Receipt of the proceeds of a settlement may adversely affect the seller’s eligibility for Medicaid, supplemental Social
Security Income or other governmental benefits or entitlements. Advice concerning possible consequences should
be obtained from the appropriate government agencies.
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4. All medical, financial or personal information obtained by Edmund R. Whitelaw or a life settlement provider 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 transact the settlement on your behalf. If the insured is asked to provide this information,
the insured will be asked to consent to the disclosure. The information may be presented to someone who buys the
policy or provides proceeds for the purchase. The insured may be asked to renew his or her permission to share
information.
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5. Following policy sale, the insured may be contacted by the provider or its authorized representative for the purpose
of determining the insured’s health status. Customarily, this contact should be limited to no more frequently than
once every three (3) months.
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6. Seller customarily has the right to rescind a settlement contract for a period of (15) calendar days after receipt of the
proceeds depending upon State regulations. If the insured dies during the rescission period, the settlement contract
shall be deemed rescinded, subject to repayment of all proceeds and other payments made by settlement provider
on behalf of seller or insured.
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7. Proceeds will be wire transferred or sent to seller directly by the provider within three (3) business days after the
provider has received the insurer’s acknowledgement that ownership of the policy or interest in the certificate has
been transferred and the beneficiary has been designated.
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8. Edmund R. Whitelaw will be compensated by the settlement provider in an amount equal to a percentage of either
the policy death benefit amount or the ‘net’ offer amount (gross offer amount less policy cash surrender value).
I acknowledge I have read and understand the contents of this disclosure and the “Important Information You Should
Know Before Entering Into a Viatical or Life Settlement” attachment.
Policy Owner Signature: _______________________________________________ Date: _______________________
Typed/Printed Name: ______________________________________________________________________________
Witness Signature: ____________________________ Printed Name ____________________Date: _______________
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AUTHORIZATION FOR THE RELEASE OF MEDICAL INFORMATION
(HIPAA Compliant)
I hereby authorize any physician, medical practitioner, hospice, hospital, clinic or other medical or medically related
facility, insurance support organization, pharmacy, or any other institution or person (“Authorized Discloser”) to provide
Edmund R. Whitelaw any and all information as to diagnosis, treatment and prognosis with respect to any physical or
mental condition including psychiatric conditions, information relating to HIV or AIDS tests, or drug or alcohol abuse as it
relates to me (hereinafter, “Protected Health Information” or “PHI”).
This authorization allows for the disclosure, inspection and copying of any and all records, reports, and/or documents,
including any underlying data regarding the care and treatment of the patient, and any other PHI concerning any
treatment or hospitalization, including, but not limited to, all testing materials completed by or administered to the
patient, along with any and all medical charts, clinical or doctor’s notes, memoranda, medical reports, X ray reports,
index cards, history notes, pictures, records and medical bills in the possession and control of the Authorized Discloser.
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By signing below, I understand that this Authorization shall apply to any and all PHI, whether or not personally
identifiable or protected under any federal or state confidentiality or privacy laws or regulations. I further understand
that PHI obtained may be used to evaluate eligibility to participate in Purchaser’s life settlement program and to
evaluate life expectancy now and in the future. Authorized Discloser, however, may not condition treatment, payment,
enrollment or eligibility for benefits upon this Authorization.
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I agree that this authorization is valid for twelve (12) months from the date thereof, and that a photocopy or facsimile is
as valid as an original.
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I understand that I may revoke this Authorization any time with respect to any Authorized Discloser by notifying such
Authorized Discloser of the revocation in writing and delivering such revocation by certified mail or personal delivery at
such address designated by the respective Authorized Discloser.
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I understand that 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”), and that PHI obtained by this
Authorization, if disclosed by authorized Designee, may no longer be protected by the HIPAA Privacy Regulations.
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_____________________________________
Insured Signature/Date Signed
____________________________________
Insured Printed Name
_____________________________________
Date of Birth
____________________________________
Social Security Number
_____________________________________
Witness Signature/Date Signed
____________________________________
Witness Printed Name
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MEDICAL INFORMATION
A separate Medical Information summary must be completed for each insured.
Insured Name: ___________________________________________________________________________
List any specific health conditions: ___________________________________________________________
________________________________________________________________________________________
Height: ____________________________ Weight: ________________
Has Insured Smoked: Cigarettes
Cigars
Pipe
In the past 12 months? Yes
Does insured use or has ever used alcoholic beverages? Yes
(A) Frequency of use? Daily
Weekly
Monthly
No
No
If yes, please answer the following:
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Occasionally
(B) Amount consumed on each occasion: _________________________________________
(C) Any treatment for alcohol use (including AA treatment)? __________________________
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Family History
Current Age
Deceased?
(A) Father
__________ Yes __ No __
(B) Mother
__________ Yes __ No __
(C) Brother/Sister __________ Yes __ No __
(D) Brother/Sister __________ Yes __ No __
If deceased, cause and age at time of death
__________________________________
__________________________________
__________________________________
__________________________________
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Primary Care Physician(s):
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Name: _____________________________________ Name: _________________________________
Address: ___________________________________ Address: ________________________________
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City, State, Zip: _____________________________
City, State, Zip: __________________________
Phone Number: ______________________________ Phone Number: __________________________
Date of last consultation: ______________________ Date of last consultation: ___________________
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Specialists:
Name: _____________________________________ Name: _________________________________
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Address: ___________________________________ Address: ________________________________
City, State, Zip: ______________________________ City, State, Zip: __________________________
Phone Number: ______________________________ Phone Number: __________________________
Date of last consultation: _______________________ Date of last consultation: ___________________
Attach additional pages, if needed.
Prescription Medications:
_______________________________________
_______________________________________
_______________________________________
_______________________________________
_______________________________________
_______________________________________
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AUTHORIZATION FOR THE RELEASE OF POLICY INFORMATION
I hereby authorize ___________________________________________________________________,
the issuer of Policy Number ___________________ and/or Certificate Number __________________
owned by __________________________________________________________________________
and insuring the life of _______________________________________________________________,
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to release to Edmund R. Whitelaw a copy of the policy, forms, riders or amendments, illustrations or verification
of coverage of this policy. I respectfully request that you reply immediately to any request for information or
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letters from Edmund R. Whitelaw pertaining to this policy or employment information. I agree that this
authorization is valid for twelve (12) months from the date thereof, and that a photocopy or facsimile is as
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valid as an original.
____________________________________
Signature of Owner
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_____________________________________
Date Signed
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_____________________________________
Signature of Witness
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Printed Name of Owner
_________________________________
Social Security Number
_________________________________
Printed Name of Witness
____________________________________
Date Signed
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EXCLUSIVE BROKER OF RECORD LETTER
FOR VIATICAL AND LIFE SETTLEMENTS
I, ____________________________________________, owner of policy number __________________
with__________________________________________ insurance company, appoint Edmund R. Whitelaw as
the exclusive Broker of Record for this policy for the purpose of negotiating the sale of said policy on my
behalf. Further, I agree not to appoint any other individual or entity as Agent/Broker of Record without
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revoking the Broker of Record agreement by written notice to Edmund R. Whitelaw. All other Agent/Broker of
Record agreements signed by me prior to the date on this Broker of Record agreement are null and void and
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all other 3rd parties shall cease and desist their marketing of said policy and shall not be communicated with
further by any potential funding sources.
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A signed photocopy of this release shall be equally as binding as a copy with my original signature.
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______________________________________________
Policy Owner or Trustee Signature
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Date ___________________________
___________________________________________________________________________________
Policy Owner or Trust Printed Name
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______________________________________________
Owner Social Security Number or Tax ID Number
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Witness
Date ___________________________
______________________________________________
Witness Printed Name
8
INSURED LETTER TO PHYSICIAN
Please prepare this letter on your letterhead and mail or deliver it to each of your physicians.
A copy of each letter must be returned with this application.
Date: __________________________
Doctor Name: ______________________________________________________
Doctor Address: _____________________________________________________
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_____________________________________________________
RE: Patient Name: ___________________________________________________
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Social Security/Medical ID#: __________________________________________
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Dear Sir or Madam:
I am currently working with Edmund R. Whitelaw to sell my life insurance policy. Mr. Whitelaw will be contacting you in
the near future in order to obtain my medical information.
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Please respond promptly to any requests received and provide them with all information requested in order to expedite
the processing of my life settlement.
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This letter will serve as acknowledgement that I consent to the release of my records and request that this letter be put
in my file for future reference, should future release of information be needed by Mr. Whitelaw.
Thank you for your time and cooperation.
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Sincerely,
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Insured’s Name
________________________________________
Printed Name of Insured
9
SUPPLEMENTAL INFORMATION QUESTIONNAIRE
The following information supplements the application information if page 3 questions were answered ‘yes’.
1. Name of initial policy owner at time of policy issuance: __________________________________________
2. Name of initial beneficiaries at time of policy issuance: __________________________________________
3. Name of current policyowner if different from question 1 above: __________________________________
4. Name of current beneficiaries if different than question 2 above: __________________________________
5. What was the insured’s and policyowner’s original purpose for buying the policy? ____________________
6. Yes/No. Before or at the time the policy was issued, did the insured, policyowner or any other party arrange to
transfer, sell or assign, directly or indirectly the policy or any benefits to a third party? If yes, please describe the
arrangement in detail and provide copies of any documents relating to the arrangement.
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7. Yes/No. Has the insured or policyowner ever assigned the policy or policy benefits to any person or entity? If yes,
please describe the details of such assignment.
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8. Yes/No. Has the policy or any of the policy premiums been financed by a third party, either through a loan, equity,
contribution or otherwise?
a. If yes, please describe the financing arrangement in detail and provide copies of any documents related to
that arrangement.
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b. If yes, what is the name of the lender? _________________________________________________
c. If yes, what is the principal loan amount? _______________________________________________
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d. If yes, what is the loan maturity balance (payoff amount)? _________________________________
e. If yes, what is the loan maturity date? _________________________________________________
9. List all persons or entities (including any trust) who have, or have had, any direct or indirect ownership or other
interest in the policy or its proceeds, including the nature of the interest and the relationship of such person or
entity to the insured. For any entity, please identify all persons that own or have owned and, if different, control or
manage (or have controlled or managed) that entity. For any trust, include all beneficiaries.
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Name: ______________________________________________________________________________
Nature of interest: ____________________________________________________________________
Date and manner interest was obtained: __________________________________________________
Relationship to insured: ________________________________________________________________
10. Yes/No. Has the policy’s beneficiary changed since the policy was issued?
a. If yes, who was the beneficiary at the time the policy was issued? ___________________________
b. If yes, what was their relationship to the insured? ________________________________________
c. If yes, why was the beneficiary changed? _______________________________________________
d. If yes, who is the current beneficiary and what is the beneficiary’s relationship to the insured? ___
_________________________________________________________________________________
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11. Yes/No. Has the insured or policyowner borrowed money directly or indirectly in connection with the policy? If yes,
please describe the borrowing arrangement in detail and provide copies of any documents relating to that
arrangement.
12. Yes/No. Are any of the interests of the policyowner in the policy pledged as security to any person or entity or
otherwise encumbered or restricted in any way? If yes, please explain in detail.
13. Yes/No. Prior to completing this application, has the insured or policy owner ever given a person or entity the right
or option to purchase the policy or a financial interest in the policy? If yes, please describe the option in detail and
provide copies of any documents relating to that option.
14. Yes/No. Does the policyowner or insured have knowledge of any information that may be used by the issuing
insurance carrier to challenge the payment of the policy’s death benefit, including whether the policyowner at the
time of policy issuance had an insurable interest in the life of the insured(s)? If yes, please explain in detail.
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Each of the undersigned insured and policyowner hereby certify that the information provided in this questionnaire is
true and correct as of the date hereof. Each of the undersigned hereby affirms its understanding that prospective
purchasers will be relying on the statements and responses which are being provided by all the undersigned in the
questionnaire, and each of the undersigned agrees, jointly and severally, to hold the purchaser and Edmund R.
Whitelaw, broker of record for sale of this policy, harmless and agrees to indemnify the purchaser and Edmund R.
Whitelaw from and against any loss, liability, fees (including attorneys’ fees) costs, expense, claim, or demand arising out
of or in connection with any such statement or response.
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First insured: ____________________ Signature of insured: __________________________ Date: ______________
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Second insured: __________________ Signature of insured: __________________________ Date: ______________
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Policyowner: ____________________ Signature of policyowner: ______________________ Date: ______________
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Important Information You Should Know
Before Entering Into a Viatical or Life Settlement
What is a viatical settlement? Viatical settlement is a transaction whereby a written agreement is
solicited, negotiated, offered, entered into, delivered, or issued for delivery in the policy owner’s state
of residency under which a viatical settlement provider acquires, through assignment, sale, or transfer
of a policy insuring the life of an individual who has a catastrophic or life threatening illness or condition,
by paying the owner or certificate holder compensation or anything of value that is less than the net
death benefit of the policy.
What is a life settlement? Life settlement is a transaction whereby a written agreement is solicited,
negotiated, offered, entered into, delivered, or issued for delivery in the policy owner’s state of
residency under which a life settlement provider acquires, through assignment, sale, or transfer of a
policy insuring the life of an individual who does not have a catastrophic or life threatening illness or
condition, by paying the owner or certificate holder compensation or anything of value that is less than
the net death benefit of the policy.
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What is a settlement ‘provider’? A provider is the entity that buys the policy.
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Is there a difference between a broker and a provider? Yes. A broker works for you, and will check with
several providers to find the best offer for you. If you use someone to help with the sale of your policy,
you should clarify whether they are a broker or a provider representative. A provider representative
works for a provider, and will only check with that provider to get you their offer.
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Can a policy owner sell the policy without the insured’s consent? No. Only the owner of the policy has
the right to sell the policy, but the owner cannot sell the policy without the insured’s consent.
How does a settlement work? Most providers or brokers ask you to complete an application along with
policy and medical release forms so that they can gather information from your life insurance company
and your doctors. All information gathered must be kept confidential and cannot be given to any party
without your written approval. If you qualify, the provider will make you an offer for the purchase of
your policy. The amount offered for your policy will be based on facts such as the insured’s life
expectancy, premium payments required by the life insurance company to sustain the policy, the
insurance company’s third party ratings, and your policy’s provisions (e.g., a waiver of premium). If you
accept a provider’s offer, you will be required to execute the provider’s life settlement contract. Upon
policy sale, the provider becomes the policy owner, designates the policy beneficiary, and is responsible
for ongoing premium payments.
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Do you have to sell all of your policy? No. Depending upon the terms of your policy contract, you may
have the option to sell all or a part of your policy. If you sell only a part, you will be required to assign or
transfer only the part being sold to the provider.
Do all life insurance companies allow policy sale? No, some carriers prohibit policy sale or condition
policy sale upon carrier approval. If you are considering policy sale, you should contact the carrier to
clarify this question.
How are the sale proceeds paid? Providers generally use an escrow agent or trustee who will wire
transfer or send the sale proceeds within three business days following the date the insurance company
confirms policy ownership transfer to the provider.
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What if you change your mind about selling the policy? If you change your mind, customarily you can
cancel the settlement contract at any time up to the 15th day after you receive payment from the
provider. To cancel the settlement contract, you must return the proceeds payment to the provider
along with an amount equal to any premiums paid by the provider to keep the policy in force. Also, you
need to arrange with the provider to have the insurance company transfer policy ownership back to
you.
What if the insured dies shortly after policy sale? If the insured dies at any time up to the 15th day
after payment by the provider, the settlement contract will automatically cancel. The provider will pay
the policy seller or beneficiaries designated by the policy seller any proceeds it receives from the life
insurance company, minus the proceeds already paid for policy purchase and any premiums paid to the
insurance company to keep the policy in force. Also, the insurance company or the provider should
refund any unearned premiums paid.
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What happens after you receive the sale proceeds? After the provider has purchased the policy, it may
periodically communicate with the insured to check on the insured’s health status.
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What if the insured doesn’t want to be contacted about his/her health status? The insured may
appoint an adult person(s) to be contacted on his/her behalf. The provider must be given the appointed
representative’s name, address and phone number. Thereafter, the provider may not contact the
insured unless it has been unable to contact the appointed representative for more than 30 days. Also,
the insured can change his/her appointed representative at any time by sending written notice to the
provider.
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Will the provider be calling the insured’s doctor to check on health status? Some providers will use the
insured’s medical release authorization to obtain health status updates. The medical release form
authorizes the insured’s doctor(s) to release medical information to the provider, broker or provider
representative. If the insured decides the provider should not contact his/her doctor, the insured has
the right to withdraw his/her medical consent in accordance with law.
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Is a fee or commission earned from the sale of your policy? Yes. Generally the broker(s) are paid a fee
equal to a percentage of the policy death benefit or the offer amount in excess of policy cash surrender
value. You have the right to request and receive the names of all brokers or agents representing you
who will receive some type of payment from the sale of your policy, along with the payment amount
and terms.
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How will you know if your policy includes extra coverage like accidental death, future increases in the
death benefit, or covers other family members? Do these affect your settlement? You should contact
your insurance company or agent to request formal confirmation that your policy does or does not
contain provisions or riders offering extra coverage. If your policy includes a benefit for accidental
death, the additional death benefit may not be included as part of your settlement. The additional death
benefit will remain payable to your beneficiaries or your estate. If your policy provides future increases
in the death benefit, you should ask how much the provider is paying you for the purchase of this
benefit. If your policy is a joint policy, or provides coverage on the lives of other family members or
anyone other than yourself, there may be a possible loss of coverage.
Are there other options available besides selling your policy? Yes. Your insurance company may offer
options, such as accelerated death benefits, loans and surrender of the policy for its cash value. Before
entering into a life settlement, you should contact your insurance company or agent to clarify the
available options.
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What other things should you know about a settlement contract?
Receipt of a settlement may affect your eligibility for public assistance programs such as medical
assistance (Medicaid), Aid to Families with Dependent children (AFDC), supplementary social
security income, and drug assistance programs.
There may be a loss of life insurance coverage on your spouse or other family members, if the
policy (or any riders attached to it) covers their lives;
The money you receive for your life insurance policy may be taxable;
The money you receive for your life settlement could be taken away from you by creditors,
personal representatives, trustees in bankruptcy and receivers in state or federal court.
This summary has been prepared for informational purposes only. You are encouraged to contact an
attorney, accountant, estate planner, financial planning advisor, tax advisor, social services agency, your
insurance company, or agent, as applicable, to evaluate the implications of selling your policy.
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