"Application for Life Settlement Provider License" - Connecticut

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

Form Details:

  • Released on July 6, 2015;
  • The latest edition currently provided by the Connecticut Insurance Department;
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  • Fill out the form in our online filing application.

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Download "Application for Life Settlement Provider License" - Connecticut

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STATE OF CONNECTICUT
INSURANCE DEPARTMENT
Fraud, Licensee Investigations and Compliance Unit
P.O. Box 816 Hartford, CT 06142-0816
APPLICATION FOR LIFE SETTLEMENT PROVIDER LICENSE
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.
1. Name/Mailing Address of Applicant:
Physical Address of the Applicant:
Name _____________________________
Physical Address _______________________
__________________________________
_____________________________________
Mailing Address ____________________
_____________________________________
__________________________________
City _________________________________
City ______________________________
State __________________ Zip ___________
State _______________ Zip ___________
Phone # ___________________________
FAX # _______________________________
e-mail address ________________________________________________________________
2. Applicant’s Organizational Type (check one):
Individual
Limited Liability Corporation
Corporation (Date of Incorporation: __/ __/ __ State of Incorporation: ___________)
Partnership
Other ____________________________________________________________________
3. Contact Person for future correspondence from Insurance Dept.: ________________________
____________________________________________________________________________
Phone # __________________________
Fax # ________________________________
E-mail address: _______________________________________________________________
4. File a narrative detailed plan of operation of the applicant that addresses the following:
• What type of marketing techniques does the applicant intend to utilize? What geographic
areas will be targeted?
• Who will produce business for the applicant and how will these persons be recruited,
trained and compensated?
• Describe the advertising, brokerage and distribution system to be used by the applicant.
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Life Settlement Provider Application
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STATE OF CONNECTICUT
INSURANCE DEPARTMENT
Fraud, Licensee Investigations and Compliance Unit
P.O. Box 816 Hartford, CT 06142-0816
APPLICATION FOR LIFE SETTLEMENT PROVIDER LICENSE
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.
1. Name/Mailing Address of Applicant:
Physical Address of the Applicant:
Name _____________________________
Physical Address _______________________
__________________________________
_____________________________________
Mailing Address ____________________
_____________________________________
__________________________________
City _________________________________
City ______________________________
State __________________ Zip ___________
State _______________ Zip ___________
Phone # ___________________________
FAX # _______________________________
e-mail address ________________________________________________________________
2. Applicant’s Organizational Type (check one):
Individual
Limited Liability Corporation
Corporation (Date of Incorporation: __/ __/ __ State of Incorporation: ___________)
Partnership
Other ____________________________________________________________________
3. Contact Person for future correspondence from Insurance Dept.: ________________________
____________________________________________________________________________
Phone # __________________________
Fax # ________________________________
E-mail address: _______________________________________________________________
4. File a narrative detailed plan of operation of the applicant that addresses the following:
• What type of marketing techniques does the applicant intend to utilize? What geographic
areas will be targeted?
• Who will produce business for the applicant and how will these persons be recruited,
trained and compensated?
• Describe the advertising, brokerage and distribution system to be used by the applicant.
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Life Settlement Provider Application
Page 1 of 10
• Describe the sources and terms of applicant’s financial resources.
• What is the total projected Connecticut business over the next five years?
• Explain each arrangement the applicant has with a bank and trustee or escrow agent to
receive and disperse funds. Attach each trust or escrow agreement.
• Give a detailed description of the corporate organizational structure of the applicant, its
parent company and all affiliates. This description should include a chart showing the
ownership percentages of all affiliated companies up to and including the ultimate
controlling person.
• Provide a detailed description of the procedures used by the applicant in handling sensitive
medical information.
5. Provide a list of the states in which the applicant is doing business as a viatical and/or life
settlement provider and indicate whether or not the applicant is licensed in that state.
6. Provide a list of all business licenses held or applied for by the applicant from any governmental
entity, the term of such license, the type of license, and the issuing governmental entity.
7. Provide a copy of the Articles of Incorporation, Partnership Agreement, Trust Agreement or other
such organizational document of the applicant certified by the proper domiciliary official.
8. Provide a copy of the by-laws of the applicant certified as true and correct by the Secretary of the
State if a corporation, a partner, if a partnership, or other appropriate person
9. Provide a current certificate of good standing from the applicant’s state of domicile and, if such
applicant is not domiciled in this state, a certificate of good standing from this state dated not more
than fifteen days before or after the date of filing of the application.
10. File an 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.
11. Any nonresident applicant must submit a 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.
12. Provide an annual statement on or before the first day of March of each year to include, 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
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Life Settlement Provider Application
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owner or the insured.
13. Provide a list of all persons responsible for the conduct of affairs of the applicant. This list should
include all officers, directors, stockholders, partners (in the case of a partnership), key managers,
employees and any other person who exercise control or influence over the affairs of the applicant.
This list must include the names of all persons acting as authorized agents for the Life
Settlement Provider. Give the name, social security number, resident address, position and
percent of ownership and the answer to the following questions for each person listed. If you
answer yes to any one of the following questions please provide a detailed explanation.
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.
Has this individual been fined, reprimanded, or been the subject of a consent decree in any state by any
agency that regulates the business of insurance, real estate, securities, or financial institutions?
Yes
No
Has this individual held or applied for a license to solicit insurance, real estate, securities, or to act as a
broker, that was refused, censured, suspended, denied, canceled, terminated, surrendered, revoked, or
had other administrative action taken against said individual in any state?
Yes
No
Has this individual been convicted or pled no contest to a misdemeanor or felony offense, or is this
individual currently charged with a misdemeanor or felony, other than a misdemeanor related to the
use of a motor vehicle?
Yes
No
If yes, provide details specifically including dates, nature of the crime and rehabilitation of the
individual. If this individual has ever been employed by an insurance company, or in the business of
real estate, securities, or financial institutions, has his or her employment been terminated or non-
renewed because of allegations of misconduct or wrongdoing?
Yes
No
Has the individual completed the attached biographical affidavit form?
Yes
No
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Life Settlement Provider Application
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Important Notice:
Viatical Settlement/Life Settlement Forms Submission
Please note that under Section 38a-465c, Connecticut General Statutes, viatical
settlement contracts and disclosure statements must be filed with and approved by the
Connecticut Insurance Department prior to use. This is a separate requirement in
addition to being a licensed viatical settlement provider in Connecticut. Refer to CGS
38a-465 and corresponding regulations for specific language and other requirements
for VS/LS forms and submit them separately to:
State of Connecticut Insurance Department
Life and Health Division
P.O. Box 816
Hartford, CT 06142-0816
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CERTIFICATION OF ACCURACY
I have read and knowingly made the foregoing statements and representations and certify that each
statement and representation is true to the best of my knowledge.
I understand that any
misrepresentation, false statement, or fraud in connection with this application may be cause for
revocation, suspension, refusal of renewal, or denial of application in addition to any other actions or
penalties or both.
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.
____________________________
Signature
____________________________
Name (Printed)
____________________________
Title
State of _________________________)
)ss:
County of _______________________)
Sworn before me this _____________ day of ____________________________, 20 _____
____________________________, Notary Public.
My Commission Expires: __________________
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