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What is a life settlement?
Why sell?
Do I Qualify?
Contact Us
Can I sell my life insurance?
1
2
Amount of Policy's Death Benefit
*
Life Insurance Carrier Name
Policy Type
*
Select an Option
I don't know
Term
Universal Life
Whole Life
Permanent ("not Term")
Other
Is the policy convertible?
Yes
No
I don't know
Did you obtain this policy through a current or former employer?
Yes
No
I don't know
How long has the policyowner owned the policy?
*
Select an Option
I don't know
< 2 yrs
2 - 3 yrs
4 - 5 yrs
6 - 10 yrs
11 - 15 yrs
16 - 20 yrs
21 - 25 yrs
> 25 yrs
Your Relationship to Insured
*
Select an Option
Self
Spouse
Child
Advisor
Caregiver
Other
Insured's First Name
*
Insured's Last Name
*
Insured's Gender
*
Select an Option
Male
Female
Insured's Age
*
Please enter a number from
0
to
120
.
Current Health of Insured
*
Select an Option
I don't know
1 - Excellent
2 - Good
3 - Fair
4 - Poor
5 - Terminal Illness
Has the insured ever been diagnosed with the following?
Insulin Dependent Diabetes
Yes
No
I don't know
What is the A1C score?
Select an Option
Under 6
6 to 7.4
7.5+
I don't know
Is the Insulin Dependent Diabetes under control?
Yes
No
I don't know
Has the insured had any complications?
Heart Disease (including pulse or rhythm issues)
Yes
No
I don't know
Does the insured have Congestive Heart Failure?
Yes
No
I don't know
How many heart attacks has the insured had in the last 3 years?
Select an Option
0
1
2
3+
Chronic Lung or Respiratory Disease (other than Asthma)
Yes
No
I don't know
Does the insured use oxygen?
Yes
No
I don't know
Does the insured have COPD?
Yes
No
I don't know
Does the insured have Emphysema?
Yes
No
I don't know
Kidney or Renal Disease
Yes
No
I don't know
What is the current stage of the disease?
Select an Option
Stage 1
Stage 2
Stage 3
Stage 4
Stage 5
I don't know
Does the insured currently require dialysis?
Yes
No
I don't know
Liver Disease
Yes
No
I don't know
Does the insured have Cirrhosis?
Yes
No
I don't know
What is the insured's liver transplant status?
Select an Option
Completed
On List (Pending)
Not Applicable
I don't know
Cancer
Yes
No
I don't know
Does the insured have any of the following types of cancer? (Check all that apply.)
Bladder
Liver
Brain
Lung
Breast
Melanoma
Colorectal
Multiple Myeloma
Digestive
Non-Hodgkin's Lymphoma
Head/Neck
Ovarian
Kidney
Prostate
Leukemia
Pancreatic
Other (list all)
Hidden
Any other cancer?
What is the insured's latest stage of cancer?
Select an Option
Stage 1
Stage 2
Stage 3
Stage 4
I don't know
Is the cancer currently in remission? (Select "No" if any type of cancer is currently active.)
Select an Option
No
Yes, less than 2 years
Yes, more than 2 years
I don't know
Multiple Sclerosis (MS)
Yes
No
I don't know
Does the MS affect the insured's bowels, bladder, or ability to walk?
Yes
No
I don't know
Stroke / Cerebrovascular Disease
Yes
No
I don't know
How many strokes or TIAs has the insured had?
Select an Option
0
1
2
3+
I don't know
Does the disease affect the insured's everyday life?
Yes
No
I don't know
Alzheimer's Disease or Dementia
Yes
No
I don't know
Parkinson's Disease
Yes
No
I don't know
Does the disease affect the insured's everyday life?
Yes
No
I don't know
ALS (Lou Gehrig's Disease)
Yes
No
I don't know
Does the insured use any assistive devices or ongoing medial support such as homecare hospice or continuous therapy?
Yes
No
I don't know
Please explain assistive devices / medical support
Please provide any additional health information for the insured
Is there another insured on the policy that is still living?
*
Select an Option
Yes
No
Relationship to Insured
*
Select an Option
Self
Spouse
Child
Advisor
Caregiver
Other
Insured's First Name
*
Insured's Last Name
*
Insured's Gender
*
Select an Option
Male
Female
Insured's Age
*
Please enter a number from
0
to
120
.
Current Health of Insured
*
Select an Option
I don't know
1 - Excellent
2 - Good
3 - Fair
4 - Poor
5 - Terminal Illness
Has the insured ever been diagnosed with the following?
Insulin Dependent Diabetes
Yes
No
I don't know
What is the A1C score?
Select an Option
Under 6
6 to 7.4
7.5+
I don't know
Is the Insulin Dependent Diabetes under control?
Yes
No
I don't know
Has the insured had any complications?
Heart Disease (including pulse or rhythm issues)
Yes
No
I don't know
Does the insured have Congestive Heart Failure?
Yes
No
I don't know
How many heart attacks has the insured had in the last 3 years?
Select an Option
0
1
2
3+
Chronic Lung or Respiratory Disease (other than Asthma)
Yes
No
I don't know
Does the insured use oxygen?
Yes
No
I don't know
Does the insured have COPD?
Yes
No
I don't know
Does the insured have Emphysema?
Yes
No
I don't know
Kidney or Renal Disease
Yes
No
I don't know
What is the current stage of the disease?
Select an Option
Stage 1
Stage 2
Stage 3
Stage 4
Stage 5
I don't know
Does the insured currently require dialysis?
Yes
No
I don't know
Liver Disease
Yes
No
I don't know
Does the insured have Cirrhosis?
Yes
No
I don't know
What is the insured's liver transplant status?
Select an Option
Completed
On List (Pending)
Not Applicable
I don't know
Cancer
Yes
No
I don't know
Does the insured have any of the following types of cancer? (Check all that apply.)
Bladder
Liver
Brain
Lung
Breast
Melanoma
Colorectal
Multiple Myeloma
Digestive
Non-Hodgkin's Lymphoma
Head/Neck
Ovarian
Kidney
Prostate
Leukemia
Pancreatic
Other (list all)
Hidden
Any other cancer?
What is the insured's latest stage of cancer?
Select an Option
Stage 1
Stage 2
Stage 3
Stage 4
I don't know
Is the cancer currently in remission? (Select "No" if any type of cancer is currently active.)
Select an Option
No
Yes, less than 2 years
Yes, more than 2 years
I don't know
Multiple Sclerosis (MS)
Yes
No
I don't know
Does the MS affect the insured's bowels, bladder, or ability to walk?
Yes
No
I don't know
Stroke / Cerebrovascular Disease
Yes
No
I don't know
How many strokes or TIAs has the insured had?
Select an Option
0
1
2
3+
I don't know
Does the disease affect the insured's everyday life?
Yes
No
I don't know
Alzheimer's Disease or Dementia
Yes
No
I don't know
Parkinson's Disease
Yes
No
I don't know
Does the disease affect the insured's everyday life?
Yes
No
I don't know
ALS (Lou Gehrig's Disease)
Yes
No
I don't know
Does the insured use any assistive devices or ongoing medial support such as homecare hospice or continuous therapy?
Yes
No
I don't know
Please explain assistive devices / medical support
Please provide any additional health information for the insured
This is not an application. You will receive a phone call in response to filling out this form.
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