Get Prequalified

Instructions:

In order to provide you with an offer or determine if you qualify for one of our settlement options, Abacus Life will need to obtain some basic medical information on the insured and life insurance policy information from the life insurance company. We will either do a medical review call or request a copy of the insured’s medical records from the insured’s primary care physician. We will also request policy information like future premium requirements from the life insurance company. The following 3 simple documents will give us authorization to go request this information.

Document 1: Life Settlement Questionnaire

Please complete the 1-page questionnaire to the best of your ability. Leave blank anything you do not know or are uncomfortable providing.

Document 2: Authorization for the Disclosure of Protected Health Information. HIPAA Compliant

This form gives us the authority to do a medical interview over the phone and when needed gives us the authority to order medical records. Please be sure to fill in only the insured’s information and signature.

Document 3: Life Insurance Information Release

This form will be used to send to your life insurance company. This form will allow your insurance company to provide us with information about your policy, including future premiums, loans, issue date, etc. Please be sure that only the policy owner signs this document. The policy owner is not always the same as the insured, such as when a policy is trust owned in which case the trustee is the policy owner.

Life Settlement Questionnaire

Life Settlement Questionnaire

Policy Type (Please Check One):

Medical Questionnaire

PERSONAL DATA: (PLEASE COMPLETE FOR EACH INSURED)
Please describe your current living situation:

LIFESTYLE:

How often do you exercise?
Do you participate in social activities outside the home? If yes, what do you do?

MEDICAL

 

Have you ever consulted a doctor, been treated for and/or been diagnosed with any of the following conditions? Please check all that apply

LIFE INSURANCE INFORMATION RELEASE FORM

I hereby authorize the issuer of life insurance policy number,
owned by:
owned by:
to release to Abacus Life, and/or its agents, successors, assignees and affiliates, and their authorized representatives,
any and all information concerning the above policy (including any conversions thereof or replacements
therefore). This includes, but is not limited to, a complete copy of all policies and policy forms, master policies
and certificates for any group policies, all applications, policy illustrations, verification of coverage forms, annual
or periodic statements, premium information, change of ownership forms, change of beneficiary forms, and
collateral and/or absolute assignment forms, as well as all other information reflecting ownership of and benefits
payable under the policy, liens and assignments, premium waivers, and all provisions of the policy related to the
foregoing. This Release shall be effective from the date of signature until the expiration of two (2) years
following the death of the Insured(s). However, if any governing law or regulation limits this authorization to a
shorter period of time, then this Release shall remain in force for the maximum period of time allowed by law. I
understand and agree that I may be asked to renew this authorization as necessary by Abacus Life, and/or its
agents, successors, assignees and affiliates, and their authorized representatives. I agree that any copy or facsimile
of this Release shall be as valid as the original. This Release may be signed in counterparts if required to complete
execution. This Release is effective as to each Insured and each Policy Owner immediately upon witnessing of
such individual’s signature, and is not conditioned upon signature by other insureds or policy owners. It shall be
sufficient that the signature on behalf of each party appear on one or more such counterparts. However, witnesses
must sign the same sheet at the same time as signature of the person whose signature is being witnessed.

Authorization for the Disclosure of
Protected Health Information
HIPAA-Compliant

I, the undersigned, authorize the disclosure of my protected health information (the “PHI”) as defined under the applicable privacy regulations promulgated pursuant to the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) as follows:

Classes of Persons Authorized to Disclose My Protected Health Information: I hereby authorize each physician, doctor, physician practice group, nurse, hospital, medical facility, pharmacy, pharmacy benefits manager, any health care provider, any other person/entity in possession of my medical/health information and any party issuing or having access to my death certificate after my demise (each considered an “Authorized Discloser”) to disclose any and all of my PHI as provided under this authorization. I further authorize each Authorized Discloser to rely upon a photo static or facsimile copy or other reproduction of this authorization. This authorization terminates any agreement I may have made with my health care provider(s) to restrict my PHI and I instruct my provider(s) to release and disclose my entire medical record without restriction.

Classes of Person Authorized to Receive My Protected Health Information: I authorize my PHI to be disclosed by each Authorized Discloser under this authorization to any of the following persons or entities (each, an “Authorized Recipient”): (a) Abacus Life (“Viatical Settlement Provider”), (b) any entity/person with whom Viatical Settlement Provider has a contract, directly or indirectly, for services, which may include, but shall not be limited to, a life expectancy evaluator, tracking or monitoring service, records retrieval service and/or escrow agent, (b) any viatical/life settlement broker relative to a life insurance policy insuring the undersigned’s life, (c) any insurance company that has issued a life insurance policy insuring the undersigned’s life, (d) any shareholder, owner, partner, manager or member, director, officer, agent, advisor, employee or representative of an Authorized Recipient, (e) any entity/person who may seek to purchase an in-force life insurance policy which insures the undersigned’s life or who currently owns a life insurance policy insuring the undersigned’s life and (f) any and all respective successors and assigns of an Authorized Recipient.

Description of Protected Health Information Authorized for Disclosure and the Purpose for Such Disclosure: This authorization shall apply to any and all of my PHI, including but not limited to, medical records, x-ray reports, charts, laboratory reports, test results, prescription medicine information, or similar information or knowledge of me or my health condition, including but not limited to, PHI relating to AIDS/ ARC/HIV, alcohol and/or drug abuse, mental health issues and communicable diseases, whether or not personally identifiable or protected under any federal or state confidentiality or privacy law or regulations. This authorization and all disclosures of my PHI made under this authorization are for the purposes of allowing the Authorized Recipient to: (1) analyze, assess, evaluate or underwrite my health status, medical condition or life expectancy or to allow for the analysis, assessment, evaluation or underwriting of my health status, medical condition or life expectancy in connection with all aspects of a viatical/life settlement transaction, and, (2) to verify, monitor or update my PHI through a process known as “tracking” or “monitoring” of my health, medical status, or life activities should the Authorized Recipient be retained to perform such activities.

Expiration and Right to Revoke Authorization: This authorization shall remain valid until, and shall expire, one (1) year after the date of my death. I acknowledge and understand that I may revoke this authorization at any time with respect to any Authorized Discloser by notifying such Authorized Discloser of my revocation of this authorization in writing and delivering my revocation by mail or personal delivery at such address designated by such Authorized Discloser provided any revocation of this authorization, shall not apply to the extent that an Authorized Discloser has taken action in reliance upon this authorization prior to receiving notice of my revocation.

Inability to Condition Treatment, Payment, Enrollment or Eligibility for Benefits on Provision of Authorization: I understand that no Authorized Discloser or other covered entity may condition my treatment, payment, enrolment, or eligibility for benefits on whether I sign this authorization.
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”). I further understand that, as a result of this authorization, there is the potential for my PHI that is disclosed by any Authorized HCP to an Authorized Recipient to be subject to re-disclosure by the Authorized Recipient and my PHI that is disclosed to such Authorized Recipient 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 contained in this authorization is true and correct. I further certify that this authorization is written in plain language and that I have received and retained a copy of this signed authorization for future reference.

Get Prequalified