"Life Settlement Provider Renewal Application Form" - Connecticut

Life Settlement Provider Renewal Application Form is a legal document that was released by the Connecticut Insurance Department - a government authority operating within Connecticut.

Form Details:

  • Released on July 1, 2015;
  • The latest edition currently provided by the Connecticut Insurance Department;
  • Ready to use and print;
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  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Connecticut Insurance Department.

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Download "Life Settlement Provider Renewal Application Form" - Connecticut

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STATE OF CONNECTICUT
INSURANCE DEPARTMENT
P.O. Box 816, Hartford, CT 06142 - 0816
General Instructions: Applications must be submitted electronically to the attention of:
peter.nakano@ct.gov. A check in the amount of $40.00 must also be submitted to the above address.
Checks should be made payable to: “Treasurer, State of Connecticut.” Each such license shall expire
on the last day of March of each year.
Life Settlement Provider Renewal Application
Life Settlement Provider: __________________________________ Date Sent: __________________
Contact for questions or future correspondence: ____________________________________________
Address: __________________________________________________________________________
__________________________________________________________________________________
Phone #:________________________________ FAX#: ____________________________________
E-mail address: ____________________________________________________________________
Current License Expiration Date: _______________________________________________________
LSP Tax Identification Number (TIN/FEIN) ______________________________________________
$40 Fee, Check Made Payable to the Treasurer, State of Connecticut is attached
Failure to complete & return this form with your fee will result in non-renewal of your
provider license. Please allow a minimum of 30 days to ensure your application will be
renewed on time.
Attached is a copy of a certificate of good standing from the domiciliary state of this entity (if
different) dated no more than fifteen (15) days before or after the date of this renewal filing
Attached is the antifraud plan that includes the following:
• A description of the procedures for detecting and investigating possible fraudulent
insurance acts.
• A description of the procedures for reporting fraudulent insurance acts.
• A description of the plan for antifraud education and training of its underwriters and
other personnel.
• A written description or chart outlining the arrangement of the antifraud personnel
responsible for the investigation and reporting of possible fraudulent insurance acts and
investigating unresolved material inconsistencies between medical records and insurance
applications.
Revised 10/01/2009
Life Settlement Provider License Renewal
Page 1 of 3
STATE OF CONNECTICUT
INSURANCE DEPARTMENT
P.O. Box 816, Hartford, CT 06142 - 0816
General Instructions: Applications must be submitted electronically to the attention of:
peter.nakano@ct.gov. A check in the amount of $40.00 must also be submitted to the above address.
Checks should be made payable to: “Treasurer, State of Connecticut.” Each such license shall expire
on the last day of March of each year.
Life Settlement Provider Renewal Application
Life Settlement Provider: __________________________________ Date Sent: __________________
Contact for questions or future correspondence: ____________________________________________
Address: __________________________________________________________________________
__________________________________________________________________________________
Phone #:________________________________ FAX#: ____________________________________
E-mail address: ____________________________________________________________________
Current License Expiration Date: _______________________________________________________
LSP Tax Identification Number (TIN/FEIN) ______________________________________________
$40 Fee, Check Made Payable to the Treasurer, State of Connecticut is attached
Failure to complete & return this form with your fee will result in non-renewal of your
provider license. Please allow a minimum of 30 days to ensure your application will be
renewed on time.
Attached is a copy of a certificate of good standing from the domiciliary state of this entity (if
different) dated no more than fifteen (15) days before or after the date of this renewal filing
Attached is the antifraud plan that includes the following:
• A description of the procedures for detecting and investigating possible fraudulent
insurance acts.
• A description of the procedures for reporting fraudulent insurance acts.
• A description of the plan for antifraud education and training of its underwriters and
other personnel.
• A written description or chart outlining the arrangement of the antifraud personnel
responsible for the investigation and reporting of possible fraudulent insurance acts and
investigating unresolved material inconsistencies between medical records and insurance
applications.
Revised 10/01/2009
Life Settlement Provider License Renewal
Page 1 of 3
Attached is the plan of operation if changed from prior year filing.
Attached is written designation of an agent for service of process, or written irrevocable consent
that any action against the applicant may be commenced against the applicant by service of
process on the Commissioner.
Attached is the annual statement as of first day of March that includes, for any life policy
acquired under a life settlement contract within five years of the policy’s original issuance, (1)
the total number, aggregate face amount, and life settlement proceeds of policies settled during
the immediately preceding calendar year and (2) a breakdown of the information by policy issue
year, the names of the insurance companies whose policies have been settled, and the brokers
involved. The information required is limited to those transaction where the insured is a
Connecticut resident and must exclude individual transaction data that could be used to identify
the owner or the insured.
Attached are changes to the existing application on file with the Insurance Department for the
above life settlement provider, along with the appropriate supporting documentation.
Identity of Stockholders owning 10% or more of the shares.
Has any member, director or officer ever been convicted of a crime or been found guilty of
fraudulent or dishonest practices.
Has any member, etc. ever been subject to administrative proceeding involving violations of
insurance laws relating to life settlements.
A provider that willfully fails to file an annual statement as required in this section or willfully fails to
reply not later than thirty days to a written inquiry by the Commissioner in connection therewith, shall,
in addition to other penalties provided by this part, be subject upon due notice and opportunity to be
heard to a penalty of up to two hundred and fifty dollars per day of delay, not to exceed twenty-five
thousand dollars in the aggregate, for each such failure.
Revised 7/1/2015
Life Settlement Provider License Renewal
Page 2 of 3
CERTIFICATION OF ACCURACY
I certify on behalf of the Applicant, that the Applicant intends to act in good faith as a life settlement
provider and to comply with all applicable Connecticut laws and with all applicable rules and orders of
the Connecticut Commissioner of Insurance.
I further certify that neither the applicant, nor any partner, key manager, director, officer or majority
stockholder of the applicant has been convicted of a felony.
__________________________________
Signature
__________________________________
Name (Printed)
__________________________________
Title
State of ___________________________________)
)ss:
County of _________________________________)
Sworn before me this__________________________ day of _______________________, 20_____
_____________________________, Notary Public.
My Commission Expires:_______________________
Revised 7/1/2015
Life Settlement Provider License Renewal
Page 3 of 3
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