Structure Brokers Affidavit

Affidavit and Certificate of Reliability and Assurance (NAME OF COURT) [ (CASE CAPTION) BBBBBBBBBBBBBBBBBBB_B DQ LQIDQW by his/her Parent DQG 1DWXUDO *XDUGLDQ ________________________; DQG BBBBBBBBBBBBBBBBBBB LQGLYLGXDOO\ DJDLQVW 3ODLQWLIIV 'RFNHW 1R BBBBBBBBBBBBB 6758&785( %52.(5¶6 $)),'$9,7 $1' &(57,),&$7( 2) 5(/,$%,/,7< BBBBBBBBB___BBBBBBBBB, 'HIHQGDQWV [ [Insert Name of Broker] 81'(5 7+( 3(1$/7,(6 )25 3(5-85< , BBBBBBBBBBBBBBBBBBBBBBBBBBBBRI [Insert Name of Company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 DQGRU FDVXDOW\ LQVXUHUV RI WKH VWUXFWXUHG VHWWOHPHQW SRUWLRQ RI WKH VHWWOHPHQW LQ WKLV FDVH LV BBBBBBBBBBBBB LQFOXVLYH RI DQ\ DSSOLFDEOH TXDOLILHG DVVLJQPHQW IHH DQG WKLV FRVW WR SXUFKDVH WKH SURSRVHG DQQXLW\ ZDV DUULYHG DW DIWHU D VXUYH\ RI WKH PDUNHW RI DQQXLW\ SURYLGHUV LQ RUGHU WR FRQILUP DQG REWDLQ WKH EHVW YDOXH SULFHTXDOLW\ IRU WKH SHULRGLF SD\PHQW SODQ QRZ UHFRPPHQGHG American LegalNet, Inc. www.FormsWorkFlow.com 3. (Insert name of Defendant or Insurer) payments to (Name of Annuitant): will make the following future periodic [Provide full benefit payment schedule] 4. The obligation of (Insert name of Defendant or Insurer) to make the above future periodic payments will be assigned to _________________________, the Assignee. (Assignee) may fund the obligation assumed by the purchase of an annuity from (Insert name of annuity issuer) _________________________, an A.M. Best Company rated A+ or A++ insurer. A guarantee letter will be issued by (Insert name of guarantor) to guarantee the performance of said assignee. The $VVLJQHH &RPSDQ\ DQG Annuity Issuer company above named, DUH HDFK OLFHQVHG WR LVVXH LQVXUDQFH DQG annuity products in the State of New York. The standard industry commission that we are receiving in this case is based on 4% of the (Insert name of annuity issuer) premium of $__________. This commission is paid by _________________________, the life insurer issuing the annuity policy. [If more than one broker is sharing in the commission, set forth the details supporting same]. 5. 6. 7. The annuity being provided in this case is based upon guaranteed non-life contingent payments for the plaintiff, who is presently ______ years of age, having been born on ___________________. The annuity cost set forth in number two above reflects this nonlife contingent annuity cost; [Or] The life insurer(s) providing the annuity or annuities in this case has rated the plaintiff, who is presently ____ years of age, having been born on _________________, up to age ______ by reason of plaintiff's medical condition. The annuity cost set forth in number two above reflects this rated age with regard to all life contingent annuity benefit payments Period certain only payments and Juaranteed lump sum payments are not affected Ey D rated age; [Or] By reason of said plaintiff's non life impairing medical condition, the annuity being provided in this case is based upon a standard age quote for the plaintiff, who is presently years of age _________ having been born on ______________. The annuity cost set forth in number two above reflects this standard age rating. Period certain only payments and guaranteed lump sum payments are not affected by a rated age. Medical underwriting is inapplicable in guaranteed non-life contingent cases; [Or] No medical underwriting has taken place or will take place after the agreement to settle has been reached without full disclosure to both plaintiff and defendant. No post settlement medical underwriting has or will take place to secretly reduce the defendant¶s cost. 8. 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