Please download the PDF application here and either fax the completed form to (440) 358-0625 or mail it to:
8500 Station Street
Mentor, Ohio 44060
The following is the Life Settlement Inquiry Privacy Notice. Please give this notice to the proposed client (if you are an agent of the proposed client).
YOUR PRIVACY IS VALMARK’S HIGHEST PRIORITY
At ValMark Securities, Inc. and its affiliated companies, our customers are our highest priority. As providers of financial products and services that involve the collection of personal – and often sensitive – information, protecting the confidentiality of that information has been, and will continue to be, a top priority for ValMark. Due to the sensitive nature of this personal information, ValMark believes that you should know how your information is handled, the measures we have taken to safeguard that information and the situations in which we might share your information with select business partners. Our privacy promise to you is based upon the basic principles of trust, ethics and integrity.
THE INFORMATION COLLECTED BY VALMARK
When you work with one of ValMark’s Member Offices, certain personal and financial information is collected from you. The information is used by ValMark to help serve your financial needs and to fulfill legal and regulatory requirements. The information gathered for these purposes varies depending on the products or services that you request but may include, for example, your name, address, social security number, net worth, annual income and certain medical information.
TO WHOM YOUR INFORMATION MAY BE DISCLOSED
ValMark restricts access to your personal and financial information to those instances described below:
- Employees of ValMark. Your personal and financial information will be provided to those employees of ValMark who require the information to process the products or services being provided to you.
- Companies with which ValMark has selling agreements. ValMark will share your personal and financial information with other financial services entities, such as insurance companies and mutual fund companies, in order to effect transactions which you have requested or authorized. In such cases, those companies are prohibited, by agreement, from using information about you except for the narrow purpose for which it was given to them.
- Other Companies as necessary to process your business. Your personal and financial information will be provided to third-party administrators and vendors utilized by ValMark to effect, administer or enforce a transaction that you requested or authorized. For example, if you wish to purchase stocks, or bonds, ValMark processes that business through its clearing firm, Pershing. ValMark must share your personal information with its clearing firm in order to process that business. These companies, like those in the category above, are prohibited, by agreement, from using information about you except for the narrow purpose for which it was given to them.
- Where required by law or regulation. ValMark may be required by law or regulation to disclose your personal and/or financial information to a third party. For example, in response to a subpoena or to comply with industry rules and regulations.
- As otherwise authorized or permitted by law. For example, the law permits ValMark to respond to requests for information about you from a consumer-reporting agency.
- As authorized by you. Only upon your direction or with your permission will ValMark share your information with a third party other than as described in this notice.
ValMark will not share your non-public information with any person or company that does not agree to keep your information confidential.
PROTECTION OF INFORMATION
ValMark has instituted security procedures that limit employee access to non-public personal information to those with a business reason for knowing such information. We educate our employees so that they will understand the importance of confidentiality and customer privacy. All ValMark employees are aware of the company’s privacy guidelines and ValMark will take the appropriate disciplinary measures to enforce customer privacy assurances. ValMark maintains appropriate security standards and procedures to prevent unauthorized access to customer information and to preserve the integrity of that information.
This Privacy Notice applies to the following companies affiliated with ValMark Securities, Inc.:
ValMark Securities, Inc. – Broker Dealer and Member FINRA, SIPC | ValMark Advisers, Inc. – SEC Registered Investment Advisor
Executive Insurance Agency, Inc. – General Agency for numerous Insurance companies | ValMark Insurance Agency, LLC
NOTICE OF INFORMATION PRACTICES
This notice supplements the ValMark Securities, Inc. Privacy Notice, a copy of which was provided to you by your agent. In connections with your informal inquiry about insurance, Executive Insurance Agency/ValMark Securities, Inc. will collect information needed to underwrite your potential application. For this purpose only, this information may be redisclosed to one or more of the entities listed below: insurance companies or their reinsurers, life settlement underwriters or life expectancy providers, or other named financial services intermediaries.
Executive Insurance Agency/ValMark Securities, Inc. represents the following financial services entities:
Abacus Settlements, American General, American National, American Viatical Services, AXA, Banner Life, Bear Stearns and Co., Berkshire Settlements, BMI Financial, CMG Surety, Corry Capital Advisors, Coventry First, Credit Suisse, Diamond Capital, EMSI, Fairmarket LS Corp., Fasano Associates, Genworth, Great West Growth, Habersham Funding, Hartford, ING, Institutional Life Services, John Hancock, Legacy Benefits, Life Equity, Life Settlement Providers, Life Settlement Solutions, The Lifeline Program, Lincoln Benefit, Lincoln Life, Magna Administrative Services, Maple Life, Met Life Investors, Minnesota Life, Mutual of Omaha, New York Life, Peachtree, Phoenix, Portsmouth, Principal, Proverian, Prudential, Q-Capital, Silver Point Capital, Standard, Sun Life, Transamerica, United of Omaha, U.S. Financial, Vespers Financial Group, West Coast Life, 21st Services, The Life Settlement Group
MIB (MEDICAL INFORMATION BUREAU) DISCLOSURE
Information you provide will be treated as confidential. The insurance companies listed in this Notice or their reinsurers may, however, make a brief report to the Medical Information Bureau (the Bureau), a non-profit membership organization of life insurance companies, which operates an information exchange on behalf of its members. Upon request by another member insurance company to which you
have applied for life or health insurance or to which a claim is made, the Bureau will supply such company with the information it may have in its files.
Upon receipt of a request from you, the Bureau will arrange disclosure of any information it may have in your file. If you question the accuracy of the information in the Bureau’s file, you may contact the Bureau and seek correction in accordance with the procedures set forth in the Federal Fair Credit Reporting Act. You may write the Bureau at PO Box 105, Essex Station, Boston, MA, 02112 (telephone number: 612.426.3660).
FEDERAL FAIR CREDIT REPORTING DISCLOSURE
In connection with your informal inquiry about insurance, an investigative consumer report may be prepared concerning your character, general reputation, personal characteristics, and mode of living, except as may be related directly or indirectly to your sexual orientation. This information will be obtained through personal interviews with your friends, neighbors, and associates. Upon written request to the life insurance companies listed in this notice, their underwriter will disclose to you whether or not an investigative consumer report was done. If a report was done, you will be advised of the name, address and telephone number of the consumer reporting agency to whom the request was made and you have the right to request a copy.