Safe Harbour Insurance
40 industrial Park Rd. Suite 301
Plymouth, MA 02360
800-508-7311 toll free
508-746-7990 voice
508-746-7991 fax

VIATICAL/SENIOR SETTLEMENT APPLICATION
The information you provide in this application will be held in strict confidence to conduct a preliminary evaluation of the possibility of selling your life insurance policy. By returning this application to Safe Harbour Insurance Agency, by no means binds either party to any further action

*Items in blue must be completed

PERSONAL INFORMATION

1. Full Name

2. Address

3. City
 State
 Zip

4. Date of birth

5. Home Telephone with area code

6. Work Phone / Ext.:

7.  Email

8. Best Time To Contact

POLICY INFORMATION

8. List Life Insurance Company the policy is issued from.

9. What type of policy is it?

9a. If term policy. What type?

10. Policy Number

11. Face Amount of Policy
$

12. Date of Issue ie.2/1/00

13. What is the Premium Amount you pay on the policy?
$

14. Please indicate payment mode

15. Are there any loans against the policy? Yes No

16. Are you the owner of this policy? Yes No

17. Is there a disability waiver of premium on this policy? Yes No

17a. IF YES to #19, Are the premiums being paid by this rider? Yes No

18. Who is the beneficiary of this policy?

18a. If other to #20, please list relationship

MEDICAL CONDITION

19. Please state your current medical condition?

20. Are you terminally Ill? Yes No

21. When were you first diagnosed? Ie.2/1/00

22. DO YOU HAVE A FAMILY HISTORY OF:

TUBERCULOSIS Yes No
DIABETES Yes No
CANCER Yes No
HEART DISEASE Yes No
LIVER/KIDNEY DISEASE Yes No
MENTAL ILLNESS Yes No

23. LIST THE FOLLOWING INFORMATION ABOUT IMMEDIATE FAMILY MEMBERS:

RELATIVE AGE IF DECEASED, CAUSE OF DEATH AGE AT DEATH
FATHER
MOTHER
BROTHER
BROTHER
SISTER
SISTER

24. Questions and/or Comments

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Important Note: Quotes will be based on the information provided. It is only a rate calculation and is not binding in any way. A full application must be completed and signed by the named insured.