Transcription
LIFE SETTLEMENT QUALIFIERD I R E C TSECTION 1 PRIMARY CONTACTName EmailPrimary phone number ( ) Best time to callmorningafternooneveningSECTION 2 POLICY DETAILSLife Insurance Policy Information (If more than one policy is being submitted, please attach additional page(s) as necessary.)1. Insurance company Policy number2. Face amount Total policy loan Issue date3. Type of policygrouptermuniversal lifewhole lifesurvivorship universal lifesurvivorship whole lifeMM/DD/YYYYvariable universal lifeother (please specify) Is there a return of premium rider on the policy?YESNOPolicyowner(s) Information (If there are multiple owners, please attach additional pages as necessary.)4. Name of policyowner(s)5. Name of contact(s) (if corporate owned)6. Name of trustee(s) (if trust owned)7. Social security or tax ID number8. Address City State ZIP9. Primary phone number ( )10. Marital statussinglemarrieddivorcedlegally separatedwidowed11. Are you a U.S. citizen? If no, specify country of citizenshipYESNOSECTION 3 INSURED LIFESTYLE DETAILSFor survivorship policies, please complete separate qualifier for second insured. (Please attach additional page(s) as necessary.)Name Phone number ( )Address City State ZIPHeight Weight Social security number Date of birth Sexmalefemale1. Are you a U.S. citizen? If no, specify country of citizenshipYESNO2. Has your weight changed in the last year? If yes, provide detailsYESNO3. Do you currently, or have you ever smoked cigarettes? If yes, for how many years?YESNO4. Do you use any other form of tobacco or nicotine? If yes, indicate type and frequencyYESNO5. Do you drink beer, wine or spirits? If yes, indicate type and frequencyYESNO6. Are you currently employed? If yes, indicate occupation and hours per weekYESNO7. Are you involved in hobbies, clubs, organizations, travel or volunteer work? If yes, indicate type and frequencyYESNO8. Do you have a valid driver’s license? If yes, license numberYESNO9. Do you engage in sports or regular exercise? If yes, indicate type and frequencyYESNOotherYESNO11. Do you live in an assisted living facility, skilled nursing facility, or nursing home? If yes, for how long?YESNO12. Are you the primary caregiver for a dependent family member? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .YESNOMM/DD/YYYYIf yes, how many daily? Date of last use (if currently, write “current”)10. Do you live alone? If no, with whom?Insured’s initialsspousesignificant otherPage 1 of 5
SECTION 3 INSURED LIFESTYLE DETAILS (continued)13. Do you require assistance to perform any of the following activities? (Please check all that apply.) . . . . . . . . . . . . . . . . . . . . . . . . . .meal planningtaking medication driving shopping walking bathing dressingIf yes, provide detailsYESNO14. Do you have any pets? If yes, provide detailsYESNO15. Do you have any children? If yes, how often do you see them?YESNOrarely . . . . . . . .YESNO17. Do you have sleep problems? (Please check all that apply.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .snoring difficulty falling asleep difficulty staying asleep tired/sleepy during the daygasping, choking, repeated pauses in breathing while sleeping unusual behavior(s) during sleep - walking or talkingmorning headache otherYESNOdaily16. Do you have any grandchildren? If yes, how often do you see them?weeklydailymonthlyweeklyyearlymonthlyrarely . . . . . . . . . . . .yearly18. Typical bedtime Number of hours of sleep per night Number of times you get up per nightSECTION 4 MEDICAL HISTORY, CONDITIONS AND TREATMENTSIn the past five years, have you been diagnosed with or treated for any of the following conditions?(Please check all that apply and provide details on page three.)1. Disease or disorder of the heart? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .high blood pressure atrial fibrillation irregular pulse other cardiac arrhythmia heart attackangina (chest pain) coronary artery disease valve disease heart failure otherYESNO2. Circulatory or blood vessel disorder? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .strokeTIA (mini-stroke) aneurysm arterial blockage in the neck, abdomen or legsvenous disease such as blood clots, thrombosis or embolism otherYESNO3. Cancer? (not including non-melanoma minor skin cancer) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .tumor or malignancy of any kind leukemia lymphoma multiple myeloma other cancerous disorderYESNO4. Immune system disorder? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .HIV autoimmune disease lupus connective tissue diseaseYESNO5. Disease or disorder of the digestive system? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .diabetes liver disease colon or rectum small intestine esophagus or stomach GI bleeding otherYESNO6. Infectious disease? (other than common cold) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .hepatitis pneumonia sexually transmitted disease sepsis shingles urinary tract MRSA otherYESNO7. Disease or disorder of the lungs or respiratory system? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .asthma COPD, emphysema or chronic bronchitisshortness of breath at rest or with minimal exertionchronic infection otherYESNO8. Genitourinary problems, disease or disorder? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .genitalia breasts prostate bladder kidney disease or failure urine abnormalities otherYESNO9. Abnormality of the blood, platelets or blood forming organs? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .anemiahigh cholesterol or triglycerides myelodysplastic syndrome abnormalities of platelets, white or redblood cells abnormal bruising, bleeding or clotting disorder of the spleen, bone marrow or lymph nodes otherYESNO10. Bone, joint or nerve abnormality, injury or accidental fall? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .paralysis or physical impairment trauma or injury gout numbness problems with balance or walkingaccidental fall arthritis osteoporosis fracture of hip, vertebra or other bone otherYESNO11. Neurological disorder? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Parkinson’s disease multiple sclerosis ALS loss of consciousness convulsions or epilepsypoor vision poor hearing neuropathy chronic pain sleep apnea otherYESNO12. Mental or nervous disorder? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .memory or cognitive impairment without dementia Alzheimer's or other type of dementia depression anxietyschizophrenia otherYESNO13. Alcohol and drug use? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .alcoholism or alcohol abuse illegal drug use marijuana prescription drug abuseadvised by a medical professional to reduce or eliminate alcohol or drug use, including prescription drugsinpatient treatment for drug or alcohol useYESNOInsured’s initialsPage 2 of 5
SECTION 4 MEDICAL HISTORY, CONDITIONS AND TREATMENTS (continued)14. Have you ever had a transplant of any organ or tissue, been diagnosed with, been treated for, had surgery,or are currently being treated for any other disease or disorder, or had an accident or injury not previously listed? . . . . . . .YESNO15. Health screen history (if known)Blood pressure / Blood tests: Cholesterol Blood sugar Ejection fractionDETAILSFor any condition checked in section four, please provide full details including diagnosis, date of diagnosis, date last treated, type oftreatment(s) received, results, additional details. (Please attach additional page(s) as necessary.)Diagnosis Date of diagnosisMM/DD/YYYYType of treatment received Date last treatedMM/DD/YYYYResultsDiagnosis Date of diagnosisMM/DD/YYYYType of treatment received Date last treatedMM/DD/YYYYResultsDiagnosis Date of diagnosisMM/DD/YYYYType of treatment received Date last treatedMM/DD/YYYYResultsDiagnosis Date of diagnosisMM/DD/YYYYType of treatment received Date last treatedMM/DD/YYYYResultsDiagnosis Date of diagnosisMM/DD/YYYYType of treatment received Date last treatedMM/DD/YYYYResultsSECTION 5 FAMILY HISTORY AND PRESCRIPTION MEDICATION1. Family History (Please attach additional page(s) as necessary.)Age, if livingIf deceased, age at deathCause of alefemaleChildmalefemaleChildmalefemaleInsured’s initialsPage 3 of 5
SECTION 5 FAMILY HISTORY AND PRESCRIPTION MEDICATION (continued)2. Do you take any medications currently? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Please include over-the-counter (OTC) medications and vitamins. (Please attach additional page(s) as necessary.)YESNOMedication name How long prescribedFor what condition Dosage and frequencyMedication name How long prescribedFor what condition Dosage and frequencyMedication name How long prescribedFor what condition Dosage and frequencyMedication name How long prescribedFor what condition Dosage and frequencyDo you use any non-prescription alternative treatments such as herbal remedies? If yes, indicate type and frequencyYESNOSECTION 6 PHYSICIAN INFORMATION1. Primary Care PhysicianName Phone ( )Address City State ZIPDate of last visit Reason for last visitMM/DD/YYYY2. Specialty Care PhysiciansList those who have treated you in the last five years. (Please attach additional page(s) as necessary.)Name Phone ( )Address City State ZIPDate of last visit Reason for last visitMM/DD/YYYYAddress City State ZIPDate of last visit Reason for last visitMM/DD/YYYYName Phone ( )Address City State ZIPDate of last visit Reason for last visitMM/DD/YYYYCoventry Direct LLC (“Coventry Direct”) is a marketing company and not a life settlement provider or broker. Coventry Direct will refer qualifiedpolicies to a licensed entity which may or may not be affiliated with Coventry Direct.I hereby acknowledge that Coventry Direct may provide this qualifier and any and all information provided herein, including my personal and/orhealth related information, to Coventry Direct’s affiliates, as well as non-affiliated contracted parties, for the purpose of evaluating and qualifyingfor a life settlement, one or more life insurance policies under which my life is insured.I hereby represent and warrant that any and all information provided by me in this qualifier is true and correct as of the date hereof. I herebyaffirm my understanding that Coventry Direct, any of its affiliates, and/or any of their respective directors, officers, employees, agents, independentcontractors, service providers or other authorized representatives (each, an “Indemnified Person”) will be relying on the statements and responsesmade by me in this qualifier, and I agree to hold each Indemnified Person harmless and agree to indemnify each Indemnified Person from andagainst any loss, liability, expense, claim or demand arising out of or in connection with any such statement or response.Name of insuredSignature of insured930 Harvest DriveBlue Bell, PA 194221-800-COVENTRYDateCoventryDirect.comPage 4 of 5 2014 Coventry Direct LLC. All rights reserved. 08.14Name Phone ( )
AUTHORIZATION(Please sign and include this authorization to release medical and policy information.)I hereby authorize each physician, doctor, physician practice group, nurse, pharmacy, pharmacy benefits manager, hospital, clinic and/or any otherhealthcare provider identified below (each, an “Authorized Discloser”) to provide Coventry Direct LLC and/or any of its affiliates, directors,officers, employees, agents, independent contractors, service providers or other authorized representatives (“Coventry”), any and all informationand/or records as to diagnosis, treatment and/or prognosis (including any and all dates thereof) concerning my past, present or future physicalor mental history or condition. I also specifically authorize each Authorized Discloser to release to Coventry the results of any HIV or AIDS testas well as any other information relating to sexually transmitted diseases, drug or alcohol abuse and psychiatric evaluations and/or information.I understand that all medical information disclosed hereunder will be treated as confidential and will only be used by Coventry in connection withthe evaluation and qualification for a life settlement or other mortality-based product. I further understand that I am not required to sign thisAuthorization in order to obtain healthcare benefits (treatment, payment or enrollment).I hereby authorize my insurance company to furnish Coventry with any information or forms in connection with any life insurance policy underwhich my life is insured (including any conversions or replacements).I acknowledge and understand that I may revoke this Authorization at any time with respect to any Authorized Discloser by notifying suchAuthorized Discloser or Coventry of my revocation of this Authorization in writing and delivering my revocation by mail or personal delivery atsuch address designated by such Authorized Discloser; provided, that, any revocation of this Authorization shall not apply to the extent that (i) theAuthorized Discloser has taken action in reliance upon this Authorization prior to receiving notice of my revocation or (ii), if this Authorizationwas obtained as a condition of obtaining insurance coverage, other law provides an insurer with the right to contest a claim under an insurancepolicy.I understand that this Authorization is not a consent or an authorization requested by a healthcare provider, healthcare clearinghouse or healthplan covered by the privacy regulations promulgated pursuant to the Health Insurance Portability and Accountability Act of 1996 (the “HIPAAPrivacy Regulations”). I further understand that, as a result of this Authorization, any of my medical information disclosed by any AuthorizedDiscloser to Coventry may be redisclosed by Coventry and may no longer be protected by the HIPAA Privacy Regulations.I certify that I am executing and delivering this Authorization freely and unilaterally as of the date written below and that all information containedin this Authorization is true and correct. I further certify that this Authorization is written in plain language and I fully understand its contents. I willretain a copy of this signed Authorization for future reference.I specifically authorize and request my insurance company and each Authorized Discloser to rely upon a photostatic or facsimile copy or otherreproduction of this Authorization.This Authorization shall remain valid until, and shall expire on, the date one year following the date of my death.Authorized disclosersName of insuredSignature of insuredDate of birthSocial security numberName of witnessSignature of witnessDateName of owner (if other than insured)Signature of owner (if other than insured)DateName of witnessSignature of witnessDate 2014 Coventry Direct LLC. All rights reserved. 08.14DateThis authorization may be executed in as many counterparts as may be required. It shall not be necessary that the signature on behalf of all partiesappear on each counterpart and it shall be sufficient that the signature on behalf of each party appear on one or more such counterparts.D I R E C T930 Harvest DriveBlue Bell, PA 194221-800-COVENTRYCoventryDirect.comPage 5 of 5
LIFE SETTLEMENT QUALIFIER DIRECT Life Insurance Policy Information (If more than one policy is being submitted, please attach additional page(s) as necessary.) . Coventry Direct LLC ("Coventry Direct") is a marketing company and not a life settlement provider or broker .Coventry Direct will refer qualified
