Policy Details
Tell us about the life insurance policy.
The type of life insurance policy affects its settlement value
Policy Value
What is the policy worth?
The death benefit amount stated in the policy
When was the policy issued?
Premium Information
How are premiums paid on this policy?
Loans & Additional Details
Any outstanding loans or other details?
Any loans taken against the policy value
Agent Information
Optional information about your insurance agent.
Basic Information
Who is the insured?
Your date of birth is important for accurate valuation
Contact Information
How can we reach the insured?
Information
Where does the insured live?
Additional Information
A few more details about the insured.
For verification purposes only
General Health
Rate the policyholder's overall health.
Tobacco use significantly impacts life insurance valuation
Body & Lifestyle
Physical measurements and lifestyle habits.
Medical Conditions
Any diagnosed medical conditions.
Select all conditions that have been diagnosed by a physician
Medications & Hospitalizations
Current medications and recent hospital visits.
List all prescription medications currently being taken
Additional Health Info
Family history and physician details.
Family history of heart disease, cancer, diabetes, etc.
Terminal illness or life expectancy estimates significantly impact valuation
Review Authorization
Please review the HIPAA authorization carefully.
HIPAA Authorization for Release of Health Information
Purpose: I authorize the release of my protected health information (PHI) to Living Benefits Advisory and its authorized representatives for the purpose of evaluating my life insurance policy for potential life settlement transactions.
Information to be Released: This authorization covers medical records, test results, treatment records, and any other health information relevant to the medical underwriting and valuation of my life insurance policy.
Who May Release Information: Any healthcare provider, physician, hospital, clinic, laboratory, or other healthcare facility that has provided care or services to me.
Who May Receive Information: Living Benefits Advisory, its authorized representatives, medical underwriters, and potential life settlement providers involved in the evaluation process.
Expiration: This authorization will expire two (2) years from the date of signing, unless revoked earlier in writing.
Right to Revoke: I understand that I may revoke this authorization at any time by providing written notice to Living Benefits Advisory, except to the extent that action has already been taken in reliance on this authorization.
Re-disclosure: I understand that information used or disclosed pursuant to this authorization may be subject to re-disclosure and may no longer be protected by federal privacy regulations.
Important Notice
By accepting this authorization, you are giving permission for your healthcare providers to release your medical information to Living Benefits Advisory and its partners for the purpose of evaluating your life insurance policy. This information will be used to determine the potential value of your policy in the life settlement market.
Consent
Confirm your agreement to the terms.
Electronic Signature
Sign and complete your application.
Electronic Signature Required
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your personalized policy valuation.
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