1. 1. The name, business address, and telephone number of the life settlement broker are as follows:

   Broker's (printed) name: ______________________________

   Address: ______________________________

   Telephone: ______________________________

2. 2. Pursuant to California law, the policy owner is entitled to the disclosure of the gross purchase price the life settlement provider is paying for the policy, the amount of the purchase price to be paid to the owner's life settlement broker, and the net amount of the purchase price to be paid to the owner of the policy.

   1. a. The gross purchase price (the total amount or value paid by the provider for the purchase of the life insurance policy, including all commissions and fees) paid by the life settlement provider for the policy is $ __________.
   2. b. The amount of the purchase price to be paid to the owner's life settlement broker is: $ __________

   3. c. The net amount of the purchase price to be paid to the owner is: $ __________.

      LIFE INSURANCE POLICY OWNER'S ACKNOWLEDGMENT: I have read and fully understand this disclosure form and have received a copy to keep for my records.

      LIFE INSURANCE POLICY OWNER

      LIFE SETTLEMENT PROVIDER

      By:

      By:

      Printed Name:

      Printed Name:

      Date:

      Date:

State of California Department of Insurance Life Settlement Provider Disclosure to Owner (To be provided prior to the execution of the life settlement contract)

IMPORTANT: READ THIS DISCLOSURE FORM BEFORE SIGNING ANY LIFE SETTLEMENT CONTRACT.

The Commissioner may consider any failure to provide the disclosures in this form as a basis for suspending or revoking a provider's license. You should carefully read all of the following points and seek financial, insurance, tax and other advice where appropriate.

Note: Authority cited: Section 10113.35, Insurance Code; CalFarm Ins. Co. v. Deukmejian, 48 Cal.3d 805 (1989); 20th Century Ins. Co. v. Garamendi, 8 Cal.4th 216 (1994). Reference: Section 10113.2, Insurance Code.

History

1. New section filed 7-29-2010 as an emergency; operative 7-29-2010. Emergency regulation shall remain in effect, not to be repealed by the Office of Administrative Law, unless repealed by the Department of Insurance pursuant to Insurance Code section 10113.35 (Register 2010, No. 31).

2. Change without regulatory effect amending Note filed 1-24-2012 pursuant to section 100, title 1, California Code of Regulations (Register 2012, No. 4).

3. Renumbering of former section 2548.30 to section 2548.31 and renumbering and amendment of former section 2548.29 to new section 2548.30 filed 11-25-2014; operative 1-1-2015 (Register 2014, No. 48).