Policy Valuation & Life Settlement Application

The Information herein will be held in the strictest confidence.

Insureds Information:
Insureds Name: __________________________________________________________ Social Security #: _________-_________-_________ Street Address: ___________________________________________________________ City: ___________________________ State: _________ Zip Code: __________________ Home Phone: ________________________ Work Phone: ________________________ Fax #: ___________________________E-Mail Address: __________________________ Date of Birth: ______/_______/________ Sex: Female___ Male: ___ Spouses Full Name: _______________________________________________________ Spouses Date of Birth________/_______/________ Social Security #: _________/_________/_________

Life Insurance Policy Information (Please provide for each Policy being offered for sale).
Name of Insurance Company: _______________________________________________ Face Amount: ____________________Policy Number: ___________________________ Approximate Cash Surrender Value: $_________________Issue Date: _____/_____/____ Insuring: ________Individual __________Survivorship Policy Type:___Universal ____Term ___VUL ___WL ___ Survivorship___ Group___ If Term Policy, can be converted until what date? _______/______/______ Annual Premium: $_____________ Paid:___A___SA___Q___M. Amount Paid: $______ Next Premium due date: ______/______/______ Owner of Policy: __________________________________________________________ Owners Address: _________________________________________________________ Owners Tax ID #: ________________________Phone Number: ____________________ Complete Trust or Corporation name, and names of Trustee(s) or 2 Corporate Officers: Beneficiary (ies): __________________________________________________________ Primary Beneficiarys Address:

______________________________________________

Reason for original purchase:____Estate Planning____Family Protection____Buy-Sell

Other (describe): ______________________________________________ Reason for selling: ________________________________________________________ Has an application (Life/Health) on the Insured been declined, rated or modified in any way (including this policy)? _____Yes_____ No Does the Insured have plans to purchase new life insurance? _____Yes _____No Total face value of life insurance NOT being offered for sale herewith: $___________

Medical:
Please list any specific health conditions: _______________________________________ ________________________________________________________________________ Height: __________ Weight: __________ Has Insured smoked: ___Cigarettes ___ Cigars ___Cigarillos ___ Pipe___ last 12 months? _____Yes _____ No Does Insured use or has ever used alcoholic beverages? ___Yes ___ No. If yes, please answer the following: (A) Frequency of use? ___ Daily ___Weekly ___ Monthly ___ Occasionally (B) Amount consumed on each occasion: ________________________________ (C) Any treatment for alcohol use (including AA treatment)? ________________

Family History
Father Mother Brother (s) Sister (s)

Current Age
_____________ _____________ _____________ _____________

Deceased?
__Yes __No __Yes __No __ Yes __ No __ Yes __ No

If deceased, cause & age

________________________ ________________________ ________________________ ________________________

Insureds Primary Physician (s):

Name: _____________________________ Address: ___________________________ City, State, Zip: _____________________ Phone #: ___________________________ Fax #: _____________________________ Date of last consultation: _____________ Reason: ____________________________ Name: ______________________________ Address: ____________________________ City, State, Zip: ______________________ Phone #: ____________________________ ax #: ______________________________ Date of last consultation: _______________ Reason: _____________________________

Specialists:
Name: _____________________________ Address: ___________________________ City, State, Zip: _____________________ Phone#: ___________________________ Fax #: _____________________________ Date of last consultation: _____________ Reason: ___________________________ Name: ______________________________ Address: ____________________________ City, State, Zip: _______________________ Phone #: ____________________________ Fax #: ______________________________ Date of last consultation: _______________ Reason: _____________________________

Financial:
Has Insured applied for or received a pension or compensation because of illness or injury? _____Yes _____ No If yes, give details of illness or injury: _________________________________________

Since this policy has been in force, has the Owner been a party to a: (check all that apply) ___ Civil Suit ___ Bankruptcy ___ Judgments ___ Creditor / Tax Liens ___ Divorce (Explain any checked answers on a separate page and attach all discharge papers). Does Insured have a Living Will? _____ Yes _____ No

Personal Acknowledgement:
I represent and warrant that the information contained in this application is correct and accurate and you may rely thereon and that I will immediately notify Genesis Living Benefits Services, LLC (Genesis), of any changes in the information. I further give my consent to Genesis and its agents 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 that I am submitting this application for Genesis to evaluate the purchase of my life insurance policy and that Genesis is under no obligation to purchase my policy. I acknowledge I may be contacted by Genesis regarding the information contained in this application. I understand that some or all of the proceeds from a life settlement may be taxable and that I am encouraged to consult with an attorney or tax advisor concerning this transaction. I also acknowledge that neither Genesis nor any of its affiliates or representatives have made any representations or provided any advice concerning the possible tax consequences or treatment of the proceeds of this transaction.

Owners Signature: ________________________________________________________ Type / Printed Name of Owner: ______________________________________________ Date: ________________________ Witness Signature: ________________________________________________________ Type / Printed Name of Witness: _____________________________________________ Date: ________________________

Insureds Name: _________________________________________________________ Social Security Number: ____________________________

Notice of Disclosure:
1. There may be alternatives to a Life Settlement contract, including, but not limited to, accelerated benefits, loans secured by the policy, and surrender of the policy for cash value offered by the issuer of the policy for which you may be eligible. The terms and conditions of such benefits may vary with each individual insurance carrier and/or policy. We encourage you to contact the issuer of your policy to discuss these other benefits. 2. Some or all of the proceeds of your Life Settlement may be taxable under federal income tax and/or state franchise and income tax laws. Genesis Living Benefits Services, LLC, (Genesis), strongly encourages you to consult your own attorney or tax advisor concerning this transaction. Genesis makes no representation and gives no advice concerning the possible tax consequences or treatment of the proceeds of this transaction. 3. Some or all of your Life Settlement proceeds may adversely affect your eligibility for social security income, public assistance, and public medical services including Medicaid or other government benefits or entitlements. Advice on such effects should be obtained from the appropriate government agencies. 4. Proceeds from a Life Settlement may not be exempt from claims of creditors, personal representatives, and trustees in bankruptcy and receivers in state or federal court. 5. If your policy contains a provision for double or additional indemnity for accidental death, or contains riders or other provisions insuring the lives of a spouse, dependents or others, there may be a loss of coverage. We urge you to contact the issuer of your life insurance policy for information on these provisions. 6. Entering into a Life Settlement will have an effect on payment of premiums and disposition of proceeds, cash values and dividends and may cause other right or benefits, including conversion rights and waiver of premium benefits that may exist under the policy to be forfeited by you. 7. All medical, financial or personal information solicited or obtained by Genesis about the insured, including the insureds identity or the identity of family members, a spouse or significant other may be disclosed as necessary to effect the Life Settlement between you and Genesis. 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 funds for the purchase. The insured may be asked to renew his or her permission to share information every two years. 8. Genesis or its authorized representative for the purpose of determining the insureds health status may contact the insured. This contact will be limited to no more frequently than once every three (3) months. 9. Funds will be sent to you within three (3) business days after Genesis has received the insurers or group administrators acknowledgement that ownership of the policy or interest in the certificate has been transferred and the beneficiary has been designated. 10. You have the right to rescind a Life Settlement contract for a period of (15) calendar days after your receipt of the proceeds. If the insured dies during the rescission period, the settlement shall be deemed rescinded. 11. Your are encouraged to contact an attorney, accountant, financial planning advisor, insurer, tax advisor or social services agency regarding potential consequences resulting from entering into a Life Settlement. Owners signature: ______________________________________Date: ____________________ Type or Print Owners Name: ___________________________SS # / Tax ID#: _______________ Insureds signature: _____________________________________Date: ____________________ Type or Print Insureds Name____________________________SS #: ______________________

HIPAA Authorization for Release of Information

(HIPAAHealth Insurance Portability and Accountability Act)

I hereby authorize Genesis Living Benefits Services, LLC, (Genesis) (my Representative) and its staff, affiliated companies and/or entities, insurance companies, funders, LE companies and their reinsurers, to possess, obtain and/or re-disclose my existing personal financial and health information for the purpose of the procurement of life, health, long term care or other insurance products or services. I authorize any health plan, physician, health care professional, hospital, clinic, laboratory, pharmacy, medical facility, Pharmacy Benefit Manager or other health care provider that has provided payment, treatment or services to me or on my behalf within the past 10 years (my Providers) to disclose my entire medical record and any other information that may be considered protected health information under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) concerning me to my Representative and its staff, affiliated companies and/or entities, insurance companies, funders, LE companies and their reinsurers. This includes information on the diagnosis or treatment of Human Immunodeficiency Virus (HIV) infection and sexually transmitted disease. This also includes information on the diagnoses and treatment of mental illness and the use of alcohol, drugs, and tobacco, but excludes psychotherapy notes. By my signature below, I terminate any agreements I have made with my Providers to restrict my medical records and any associated HIPAA protected health information and I instruct my Providers to release and disclose my entire medical record without restriction. I understand that any information that is disclosed pursuant to this authorization may be redisclosed and no longer covered by certain federal rules governing privacy and confidentiality of health information. The information contained in these medical and financial records will be held in confidence and may be used only for the purpose of the procurement, or the evaluation or underwriting for the possible procurement, of a life settlement, of life, health, long term care, or other insurance products. The contents therein may be reviewed and assessed by a qualified staff consisting of medical directors, underwriters, underwriting assistants, actuaries, or other related employees involved in the submission, receipt or evaluation of insurance/life settlement applications or prospective applications of Genesis, affiliated insurance, Funding companies and their reinsures. The records may be transmitted via U.S. regular mail, various overnight mail services and through the use of secured electronic devices. This authorization shall be valid for twelve (12) months from the date below. A copy of this authorization shall be as valid as the original. I understand that I am entitled to receive a copy of this authorization. I understand that I may write to my Representative to revoke this authorization and that the revocation will take effect when my Representative receives my written request. I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions. I understand that the medical provider to whom this authorization is furnished may not condition its treatment of me on whether or not I signed the authorization. I understand that if I refuse to sign this authorization, insurance/funding companies may not be able to offer insurance coverage or a proposal, process my application, or if coverage has been issued may not be able to make any benefit payments. I understand that my Providers may not refuse to provide treatment for health care services if I refuse to sign this authorization. Proposed Insureds Name: ____________________________SS#______________________________ Proposed Insureds Signature: ____________________________Date: __________________________ Agent/Witness: ________________________________________ Date: ___________________________

Letter to Physician

Date: _______________ Doctors Name: _____________________________________ Address: _____________________________________ ______________________________________

(City) (State) (Zip Code)

RE: Patients Name: ________________________________ Social Security/Medical ID #: _________________________ To Whom It May Concern:
I have engaged Genesis Living Benefits Services, LLC, (Genesis), in order to sell my life insurance policy. Genesis or its designated agents will be contacting you in the near future in order to obtain my medical information. Please respond promptly to any requests received and provide them will all information requested in order to expedite the processing of my Life Settlement. 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 Genesis need future release of information. Thank you for your time and cooperation.

Sincerely, _________________________________________
(Patients Signature)

Date: ___________________________

___________________________________
(Printed Name of Patient)

___________________________________
(Signature of Witness)

Date: ___________________________

Authorization to Release Insurance Information:

I hereby authorize my insurance company to furnish, Genesis Living Benefits Services, LLC, (Genesis) or its authorized representatives, life settlement providers, or brokers, any information and forms they may request in connection to my policy, (including any conversions thereof or replacements therefore). I agree that a photo static copy or facsimile of this Authorization shall remain valid for 4 (four years), absent any provision of any applicable state statue or regulation to the contrary, in which event this authorization shall remain valid for the maximum period permitted there under. I understand that all information will be kept strictly confidential. Name of Insurance Company: _______________________________Policy#:______________________ Address:______________________________________________________________________________ _ _______________________________________________________________________________
(City) (State) (Zip Code)

Name of Insured:_______________________________________________________________________ Signature of Insured:____________________________________________________Date:___________ Name of Second Insured:________________________________________________________________ Signature of Second Insured:_____________________________________________Date: ___________ Name of Owner (If other than the Insured):_________________________________________________ Signature of Owner (If other than the Insured): ______________________________Date: __________ Name of Witness:_______________________________________________________________________ Signature of Witness: ___________________________________________________Date: ___________

Exclusive Broker of Record I/We the undersigned appoint, Genesis Living Benefits Services, LLC, (Genesis), as the exclusive Broker of Record, for the Policy(s) listed below for the purpose of negotiating the sale of the Policy(s) as a Life Settlement and the undersigned agrees not to appoint any other individual or entity as a broker / agent of record with respect to sale of the Policy(s). We understand that Genesis will being investing its time and reaching out to its professional relationships to market the Policy(s) for our benefit. We represent that there have been no other Broker / Agent of Record forms signed by me / us prior to the date of this Broker / Agent of Record form that are currently effective and I/We indemnify Genesis respect to any loss related to our failure to disclose any other Brokers of Record or Agents that are entitled to a fee related to the sale of the Policy(s). I/We agree that a photographic copy or facsimile of this Broker of Record form shall be valid as the original. Insured: __________________________________Date: __________________________ Print Name of Insured: _____________________________________________________ Owner: __________________________________Date: __________________________ Print Name of Owner: ______________________________________________________ Insurance Company: ______________________________Policy Number: ___________ Insurance Company: ______________________________Policy Number: ___________ Witness: _________________________________Date: __________________________ Print Name of Witness: ____________________________________________________ Address of Insured: _____________________________________________________ _________________________________________________________ Address of Owner: ________________________________________________________ ________________________________________________________ _ Address of Witness: _______________________________________________________

Checklist for Application Package

This checklist was designed to help you ascertain if you have completed all pertinent items in order to expedite the processing of the Life Settlement application. Genesis Living Benefits Services, LLC, (Genesis), must receive the following items, in order for the policy to be processed:

Application must be filled out completely, signed and witnessed. Anything that is not applicable, mark N/A. If more than one policy, make additional copies of pages 2, 7 and 8. The release forms for Medical and Policy Information must be signed, witnessed and dated by the appropriate parties as indicated. Please make additional copies as needed. The Notice of Disclosure, must be signed and dated. Agent of Record Letter(s) signed, dated and witnessed. Insureds Photo ID. Accepted forms of identification are photocopies of a drivers license or passport. Identification must be current, not expired. Complete copy of the Insurance Policy or Policies. If this is not immediately available, please make a note for us on the application and forward as soon as possible. If Owner/Beneficiary is a Trust, we need: o Copy of Trust and Tax ID# o Trustee(s) must sign the policy information release form If Owner/Beneficiary is a Corporation, we need: o Complete name and address of the Corporation o Corporate resolution showing current authorized Officers o Two Officers must sign the policy information release form

For Agents/Brokers Only:

Broker:________________________________________________________________________ Representing Agent: _____________________________________________________________ Address:________________________________________________________________________ _________________________________________________________________________
(City) (State) (Zip Code)

___________________________________________________________________________
(Telephone/Daytime) (Fax) (Cell)

Agents Signature:__________________________________________Date:_________________

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