Form Vsb - Application For Viatical Settlement Broker (Page 4 of 4) in pdf

DECLARATION

The DECLARATION must be signed by each applicant, partner, member, director, officer, and

employee working for provider. (Make additional copies of this page as needed.)

I, the undersigned, declare under penalties of revocation or refusal of license that the statements made in this application are true,

correct and complete to the best of my knowledge and belief and that I have read and understand the Viatical Settlement Act of 2008

and related regulations, including the following Statutes.

Title 36 O.S. §4055.6(B)

Except as otherwise allowed or required by law, a viatical settlement provider, viatical settlement broker,

insurance company, insurance producer, information bureau, rating agency or company, or any other person with

actual knowledge of an insured’s identity, shall not disclose that identity as an insured, or the insured’s financial or

medical information to any other person unless the disclosure:

Is necessary to effect a viatical settlement between the viator and a viatical settlement provider and the

viator and insured have provided prior written consent to the disclosure;

Is provided in response to an investigation or examination by the Commissioner or any other

governmental officer or agency or pursuant to the requirements of subsection C of Section 13 of this act;

Is a term of or condition to the transfer of a policy by one viatical settlement provider to another viatical

settlement provider;

Is necessary to permit a financing entity, related provider trust or special purpose entity to finance the

purchase of policies by a viatical settlement provider and the viator and insured have provided prior

written consent to the disclosure;

Is necessary to allow the viatical settlement provider or viatical settlement broker or their authorized

representatives to make contacts for the purpose of determining health status; or

Is required to purchase stop loss coverage or financial guaranty insurance.

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Signature

Date

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Printed Name and Title

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Signature

Date

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Printed Name and Title

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Signature

Date

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Printed Name and Title

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FORM VSB Rev. 07302013

Form Vsb - Application For Viatical Settlement Broker Page 4