Select a page
Select a page

Life Settlement Fact Finder

    Fact Finder

    Full Name

    First Name *

    Last Name *

    Email *

    Phone Number *

    Date of Birth*

    Gender

    1. Policy Type

    Universal Life
    Variable:YesNo
    Second-To-Die: YesNo

    Term Life
    Convertible: YesNo

    Whole Life
    Cash Surrender Value *

    2. Face Amount

    Policy Loans: YesNo

    (If Yes, please provide amount) *

    Is Policy in Grace or Lapse Pending: YesNo

    (If Yes, please provide date )*

    3. Policy Issue Date

    Policy Issue Date *

    4. Name of Insurance Company

    Insurance Company *

    5. Reason for considering a Life Settlement instead of keeping policy:

    6. Has policy already been submitted for review with a Life Settlement broker or buyer?YesNo

    7. Please mark any that apply:
    Minor Health Problems: Overweight, Elevated Cholesterol, Asthma, Arthritis, Cancer that has been in remission for 5 years or longer, Osteoporosis, Diabetes (type II), Hypertension, Ulcers, Atrial Fibrillation.
    Health Changed Considerably Since Policy Issue: Hepatitis C, Pacemaker, Multiple Sclerosis, TIA, Sleep Apnea, poorly controlled Hypertension or Diabetes, Parkinson's Disease, short-term memory loss.
    Serious Health Problems: Multiple TIA’s, Heart Failure, Coronary Artery Disease, COPD, Stroke, Heart Attack, Lupus, Emphysema, Cancer (recent or recurring), Cirrhosis, Coronary Bypass, Alzheimer’s disease, aneurysm, peripheral vascular disease, valve replacement or repair.
    Clinical Diagnosis: Has insured been diagnosed with a loss of two Activities of Daily Living (ADL) or more? Has insured been diagnosed with a terminal health condition and two years of remaining life expectancy or less?
    8. Please describe any prevailing health impairment and list medications been taken:

    Health Impairment *

    Medications *

    Agent Contact

    Agent First Name *

    Agent Last Name *

    Agent Email