Texas Life Settlement Reporting Form

Life settlement provider data report

LAH323 | 0126
Instructions
- Each provider must submit an annual report, whether any reportable transactions occurred.
- Report transactions based on insured who are Texas residents.
- Prior to submission you may save a copy for your records. This annual report is due by March 1st. Refer to Texas Insurance Code Section 1111A.006.
- This online submission is completed in lieu of a hard copy or email.
- All fields marked with * are required and must be filled.
Reporting year*
It most cases, this is the previous calendar year
Provider information
TDI license number
Provider name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Contact information
Contact name
Email*
example@example.com
Phone number
Please enter a valid phone number.
EXT
Did the issuer have reportable transactions during reporting year?*

YesNo

28 Texas Administrative Code Section 3.1760(b)(3(A)-(C)

Provide aggregate data for life settlement policies:

Rows	Total number of life settlement contracts entered	Aggregate face amount of policies settled (in whole dollars)	Proceeds of life settlement contracts entered (in whole dollars)
2024
2025
2026
2027
2028
2029
2030

28 Texas Administrative Code 3.1760(3)(D)

Provide company and broker policy settlement information:

Rows	Full name of each insurance company whose policies have been settled	Full name of each broker that settled the policies
1
2
3
4
5

28 Texas Administrative Code 3.1760(3)(E)

Provide broker life settlement information:

Rows	Name of life settlement broker who estimated life expectancies for a life settlement contract	Life settlement broker's TDI license number
1
2
3
4
5

Using the buttons below, you may go back to review your entries or save and submit later. If you are ready to submit, click the 'Submit' button. You will receive email confirmation of your submission.
Should be Empty: