California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 3 - Insurers › Article 12.9 - Life Settlements › Section 2548.31 - Life Settlement Provider Annual Statement

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
State of California Department of Insurance Life
					 Settlement Provider Annual Statement (To be filed on or before March
					 1st of each year)
1.
FOR THE
							 YEAR ENDING:
2.
PROVIDER FEIN #:
DECEMBER 31,
							 ____________________.
_________________________
3.
LIFE
							 SETTLEMENT PROVIDER INFORMATION:
a.
Full name of Life
							 Settlement Provider, including all d.b.a.'s:
___________________________
___________________________
___________________________
___________________________
b.
Organized under the laws of the
							 State of:
c.
Date licensed as
							 a Life Settlement Provider:
___________________________
___________________________
d.
Address of Provider's
							 Administrative Office:
___________________________
___________________________
___________________________
e.
Is the above address
							 the location of all provider books and business records?
[] YES.
[] No, the address to
							 the location of all provider's books and business records
							 is:
___________________________
___________________________
___________________________
f.
Provider's mailing
							 address (if different from above):
___________________________
___________________________
___________________________
___________________________
g.
Name of contact
							 person:
h.
Telephone number for contact
							 person:
___________________________
___________________________
4.
LIFE SETTLEMENT PROVIDER OWNERSHIP INFORMATION:
In the table below, list
				  the name, title, percentage of ownership interest, business address, and
				  residence address of each individual who is responsible for the conduct of the
				  Life Settlement Provider's affairs, or has the ability to exercise significant
				  control over the provider, including but not limited to officers, directors,
				  trustees, partners, shareholders holding a ten percent (10%) or greater
				  interest in provider and key personnel. Place an asterisk (*) next to the name
				  of any individual not reported on the most recent Annual Statement or
				  application. Attach additional sheets if necessary. []Additional sheets
				  attached.
NAME
TITLE
%
							 OWN
BUSINESS ADDRESS
RESIDENCE
							 ADDRESS
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
LIFE SETTLEMENT PROVIDER'S ACKNOWLEDGMENT: I declare
					 under penalty of perjury that I am one of the above-described officers, owners,
					 and/or general partners of __________(name of life settlement provider), that I
					 am responsible for conducting the business of the above-named life settlement
					 provider and that the information contained in this Annual Statement, including
					 all of its schedules, answers, explanations, and attachments, is complete and
					 accurate to the best of my knowledge, information, and belief. (
Two
					 signatures required.
)
By:
___________________________
By:
___________________________
Printed Name:
___________________________
Printed Name:
___________________________
Title:
___________________________
Title:
___________________________
Date:
___________________________
Date:
___________________________
5.
POLICY INFORMATION:
a. List the total number (nationwide) of life
							 insurance policies settled during the immediately preceding calendar year:
							 __________
b. List the aggregate face amount (nationwide) for policies
							 settled during the preceding calendar year: $ __________
c. List the total number of life insurance policies
							 settled in California during the immediately preceding calendar
							 year:__________
d. List the aggregate face amount for policies settled
							 with respect to California residents during the preceding calendar year: $
							 __________
e. List the total number (nationwide) of life
							 insurance policies settled involving a retained beneficiary during the
							 immediately preceding calendar year: __________
f. List the aggregate
							 face amount (nationwide) for policies settled involving a retained beneficiary
							 during the immediately preceding calendar year: $ __________
g. List the aggregate premium commitment (nationwide)
							 for policies settled involving a retained beneficiary during the immediately
							 preceding calendar year: $ __________
h. List the total number of life
							 insurance policies settled in California involving a retained beneficiary
							 during the immediately preceding calendar year: __________
i. List the aggregate face amount for policies
							 settled with respect to California residents involving a retained beneficiary
							 during the preceding calendar year: $ __________
j. List the aggregate
							 premium commitment for policies settled with respect to California residents
							 involving a retained beneficiary during the preceding calendar year:
							 $__________
6.
Is the provider
							 submitting its audited financial statement with annual statement?
[]
							 Yes [] No
If NO, please ensure an audited financial
							 statement is provided in accordance with Section
							 2548.15.
7. GENERAL
							 INTERROGATORIES
a. Has there been any change in the
							 provider's name, organizational structure or status, Charter, Articles of
							 Incorporation, Bylaws, Partnership Agreement, affiliations, officers,
							 directors, members, owners, stockholders or location of books and records since
							 the date of the application or the last Annual statement was filed with the
							 Department?
(Note: Any provider transferring more than 10% of its stock
							 or ownership to an unlicensed provider is barred from settling policies within
							 this state until the Commissioner approves a new life settlement application
							 whenever the provider is either organized within this state or conducting at
							 least 5% of its business within the state.)
[] Yes [] No
(i)
If there has been a change, has
							 complete documentation been filed with the Department (i.e. amendments,
							 biographical affidavits, fingerprint cards)?
[] Yes [] No [] NA
(ii)
If there has been a change and
							 complete documentation was not provided to the Department, attach a complete
							 documentation.
b. Has any officer, director, member,
							 stockholder, or employee of the provider been the subject of any administrative
							 or judicial proceeding, had any license denied, suspended or revoked, been
							 arrested, indicted, convicted, or pled nolo contendere to any criminal or civil
							 action other than a minor traffic violation, or had a lien, judgment or
							 foreclosure action filed against him or her since the date of application or
							 the last Annual Statement was filed with the Department?
[] Yes []
							 No
If so, attach a detailed explanation
							 sufficient to disclose all relevant details of the matter, to include its final
							 disposition.
c. Does the provider have pending, or
							 has the provider been involved in, any legal actions, civil suits, criminal
							 proceedings, or had a license denied, suspended, or revoked by any government
							 agency or regulatory body since the date of application or the last Annual
							 Statement was filed with the Department?
[] Yes [] No
If so, attach a detailed explanation
							 sufficient to disclose all relevant details of the matter, to include its final
							 disposition.
d. During the preceding year has the
							 provider received any complaints from consumers alleging that the escrow or
							 third party trustee did not disburse the life settlement proceeds within three
							 (3) business days of receiving notification that the change in ownership or
							 beneficial interest had been effected?
[] Yes [] No
If YES, attach a list of such complaints
							 and describe what actions the provider took to correct the situation and
							 prevent its recurrence. If the settlement funds are yet unpaid, include an
							 explanation for the delay and anticipated payment date.
8. DISCLOSURE
							 INFORMATION
a. Has the provider provided all
							 disclosures required in California Insurance Code Section
							 10113.2(e)
							 and Title 10, California Code of Regulations, section
							 2548.30, including disclosure of
							 all commissions and fees paid in the life settlement transaction?
[]
							 Yes [] No
9. FORM
							 INFORMATION
a.
Has the provider filed with the
							 Department a copy of all life settlement forms to be used in
							 California?
[] Yes [] No
10. CONFIDENTIAL
							 INFORMATION
a. Was all medical or financial
							 information solicited/obtained relative to the life settlement contract treated
							 as confidential?
[] Yes [] No
11. EXAMINATION
							 INFORMATION
a.
State what date the last
							 examination on the company was made or is being made and by what insurance
							 Commissioner.
Date: ____________________ Insurance
							 Commissioner_________________________
12. ESCROW ACCOUNT
							 INFORMATION
a.
Has the provider set up an escrow
							 account wherein to deposit funds to pay its policy owners?
[] Yes []
							 No
Name the financial institution
							 where the escrow account is located and the name of the escrow agent:
Name of Financial Institution:
							 ___________________________
Name of Escrow Agent:
							 ___________________________
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
					 2548.31 to section
					 2548.32 and renumbering and
					 amendment of former section
					 2548.30 to new section
					 2548.31 filed 11-25-2014;
					 operative 1-1-2015 (Register 2014, No. 48).
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: Sections
						10113.1,
						10113.2 and
						10113.3,
						Insurance Code.