Form P-LSA: Life Settlement Provider/Broker Disclosures to Owner; Affiliations

This document has been approved by the Department of Insurance and it does not need to be filed with the Department by a broker or provider. Use this form in conjunction with Form P-LSDO. A provider or broker who intends to use a different form must submit the form for approval using the NAIC System for Rate and Form Filings ("SERFF"), accessible at http://www.serff.org.