Instructions: In order to provide you with an offer or determine if you qualify for one of our settlement options, we will need to obtain some basic medical information on the insured and life insurance policy information from the life insurance company. We will either do a medical review call or request a copy of the insured’s medical records from the insured’s primary care physician. We will also request policy information like future premium requirements from the life insurance company.

The following three simple documents will give us authorization to go request this information.

Please complete the 1-page questionnaire to the best of your ability. Leave blank anything you do not know or are uncomfortable providing.

This form gives us the authority to do a medical interview over the phone and when needed gives us the authority to order medical records. Please be sure to fill in only the insured’s information and signature.

This form will be used to send to your life insurance company. This form will allow your insurance company to provide us with information about your policy including future premiums, loans, issue date, etc Please be sure that only the policy owner signs this document. The policy owner is not always the same as the insured such as when a policy is trust owned in which case the trustee is the policy owner.

Please return these completed documents by email at sales@gjfinancialgroup.com if possible. If you need to use regular mail, please call us to assist you with a fed ex pickup service. Please call us with any questions or concerns.

Thank you and we look forward to working together!

2050 E. 96th Street, Indianapolis, IN 46240

317.751.5001 / 317.344.9495 - fax

My refusal to sign this form will not adversely affect my ability to recieve health care services, reimbursement for services, enrollment in a health plan or my eligibiity for health benefits. However, information will not be released to the above-indicated recipient without my signature.

I acknowledge that the information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and no longer protected by Federal Law.

I have the right to revoke this authorization by written notice to the healthcare Provider listed above. I understand that actions taken in reliance on this authorization cannot be reveresed, and my revocation will not affect those actions.

I, the undersigned authorize the disclosure of my protected health information (the “PHI”) as defined under the applicable privacy regulations promulgated pursuant to the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) as follows:

Classes of Persons Authorized to Disclose My Protected Health Information: I hereby authorize each physician, doctor, physician practice group, nurse, hospital, medical facility, pharmacy, pharmacy benefits manager, any health care provider, any other person/entity in possession of my medical/health information and any party issuing or having access to my death certificate after my demise (each considered an “Authorized Discloser”) to disclose any and all of my PHI as provided under this authorization. I further authorize each Authorized Discloser to rely upon a photo static or facsimile copy or other reproduction of this authorization. This authorization terminates any agreement I may have made with my health care provider(s) to restrict my PHI and I instruct my provider(s) to release and disclose my entire medical record without restriction.

Classes of Person Authorized to Receive My Protected Health Information: I authorize my PHI to be disclosed by each Authorized Discloser under this authorization to any of the following persons or entities (each, an “Authorized Recipient”): (a) Abacus Settlements, LLC (“Viatical Settlement GJ Insurance Group, LLC Provider”), (b) any entity/person with whom Viatical Settlement Provider has a contract, directly or indirectly, for services, which may include, but shall not be limited to, a life expectancy evaluator, tracking or monitoring service, records retrieval service and/or escrow agent, (b) any viatical/life settlement broker relative to a life insurance policy insuring the undersigned’s life, (c) any insurance company that has issued a life insurance policy insuring the undersigned’s life, (d) any shareholder, owner, partner, manager or member, director, officer, agent, advisor, employee or representative of an Authorized Recipient, (e) any entity/person who may seek to purchase an in-force life insurance policy which insures the undersigned’s life or who currently owns a life insurance policy insuring the undersigned’s life and (f) any and all respective successors and assigns of an Authorized Recipient.

Description of Protected Health Information Authorizd for Disclosure and the Purpose for Such Disclosure: This authorization shall apply to any and all of my PHI, including but not limited to, medical records, x-ray reports, charts, laboratory reports, test results, prescription medicine information, or similar information or knowledge of me or my health condition, including but not limited to, PHI relating to AIDS/ARC/HIV, alcohol and/or drug abuse, mental health issues and communicable diseases, whether or not personally identifiable or protected under any federal or state confidentiality or privacy law or regulations. This authorization and all disclosures of my PHI made under this authorization are for the purposes of allowing the Authorized Recipient to: (1) analyze, assess, evaluate or underwrite my health status, medical condition or life expectancy or to allow for the analysis, assessment, evaluation or underwriting of my health status, medical condition or life expectancy in connection with all aspects of a viatical/life settlement transaction, and, (2) to verify, monitor or update my PHI through a process known as “tracking” or “monitoring” of my health, medical status, or life activities should the Authorized Recipient be retained to perform such activities.

Expiration and Right to Revoke Authorization: This authorization shall remain valid until, and shall expire, one (1) year after the date of my death. I acknowledge and understand that I may revoke this authorization at any time with respect to any Authorized Discloser by notifying such Authorized Discloser of my revocation of this authorization in writing and delivering my revocation by mail or personal delivery at such address designated by such Authorized Discloser provided any revocation of this authorization, shall not apply to the extent that an Authorized Discloser has taken action in reliance upon this authorization prior to receiving notice of my revocation

Inability to Condition Treatment, Payment, Enrolment or Eligibility for Benefits on Provision of Authorization: I understand that no Authorized Discloser or other covered entity may condition my treatment, payment, enrolment, or eligibility for benefits on whether I sign this authorization.