Fillable FORM P-VOC: VERIFICATION OF COVERAGE FOR LIFE INSURANCE (Arizona)

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FORM P-VOC: VERIFICATION OF COVERAGE FOR LIFE INSURANCE (Arizona)

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The FORM P-VOC: VERIFICATION OF COVERAGE FOR LIFE INSURANCE (Arizona) form is 4 pages long and contains:

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  • 30 check-boxes
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Country of origin: US
File type: PDF

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Form P-VOC (9/18/2013) Page 1 of 4
FORM P-VOC: VERIFICATION OF COVERAGE FOR LIFE INSURANCE POLICIES
Submitted to (name of insurer) NAIC #
Policy number
Submitted from (name of life settlement provider/broker)
Street address
City State ZIP code Telephone number
Provider/broker contact person Title
INFORMATION CONCERNING THE POLICY OWNER AND INSURED
INSTRUCTIONS TO INSURER: For each item, if the information is correct, enter a check mark in the
“Insurance Company” column; otherwise, enter correct information in the “Insurance Company” column. An
asterisk indicates information the life settlement provider/broker must provide.
Life Settlement Broker/Provider Insurance Company
Owner’s name*
Address*
City*
State*
ZIP code*
Tax ID or Social Security
Number*
Insured’s name*
Insured’s date of birth*
Second insured’s name
(if applicable)*
Second insured’s date of birth (if
applicable)*
By my signature below, I hereby consent to the insurance company releasing information requested by
this form to the life settlement broker/provider.
►Policy Owner Signature_____________________________________ Date________________
Form P-VOC (9/18/2013) Page 2 of 4
POLICY STATUS, TYPE, RIDERS & OPTIONS
An asterisk indicates information the life settlement provider/broker must provide. If a question is not
applicable to the policy, enter “N/A”
Life Settlement Broker/Provider Insurance Company
Is the policy in force?
Yes
No - If “No,” skip all remaining
questions, sign and date on Page
4, and return to the life settlement
provider/broker.
Policy type* Term
Whole Life
Universal Life
Variable Life
Term
Whole Life
Universal Life
Variable Life
Original issue date**
Maturity date of policy
State of issue*
Does the policy have an
irrevocable beneficiary?*
Yes No Yes No
Is the policy currently
assigned?*
Yes No Yes No
Was the policy ever converted or
reinstated?
Yes No Yes No
Is the policy in the contestability
period?*
Yes No Yes No
Is the policy in the suicide
period?*
Yes No Yes No
Below, list all riders and, for each, indicate whether it is in a contestability or suicide period.
Contestability Suicide Contestability Suicide
Contestability Suicide Contestability Suicide
Contestability Suicide Contestability Suicide
Contestability Suicide Contestability Suicide
Contestability Suicide Contestability Suicide
Form P-VOC (9/18/2013) Page 3 of 4
POLICY VALUES
An asterisk indicates information the life settlement provider/broker must provide. If a question is not
applicable to the policy, enter “N/A”
Life Settlement
Broker/Provider
Insurance Company
Policy value as of ______________ (date)
Current face amount of policy
Amount of accumulated dividends
Current face amount of riders
Amount of any outstanding loans
Amount of outstanding interest on policy loans
Current net death benefit
Current account value
Current cash surrender value
Is policy participating?
If yes, what is the current dividend option?
Yes No
Yes No
PREMIUM INFORMATION
Life Settlement
Broker/Provider Insurance Company
Current payment mode*
Current modal premium*
Date last premium paid*
Date next premium due*
Currently monthly cost of insurance as of
_______________ (date)
Date of last cost of insurance deduction
LIFE SETTLEMENT BROKER/PROVIDER CERTIFICATION: The information submitted for
verification is correct and accurate to the best of my knowledge and has been obtained through the
policy owner and/or insured.
►Provider/Broker Signature_____________________________________ Date________________
Form P-VOC (9/18/2013) Page 4 of 4
FORMS REQUEST
1. Please provide the forms checked below
Absolute Assignment / Change of Ownership / Viatical Assignment
Change of Beneficiary
Release of Irrevocable Beneficiary (if applicable)
Waiver of Premium Approval Letter
Disability Waiver of Premium Approval Letter
Release of Assignment
Change of Death Benefit Option Form (if universal life)
Allocation Change Form (if variable life)
Annual Report
Current In-force Illustration
2. Where should completed forms be submitted for processing (enter below)?
Contact Person Name Title
Company Name
Mailing Address City State ZIP Code
Overnight Address City State ZIP Code
Telephone Number Fax Number
INSURER CERTIFICATION
(to be completed by insurance company representative)
The information provided by this insurance company verification is correct and accurate to the best of
my knowledge as of this date.
Name of Insurance Company NAIC #
Contact Person Name Title
Telephone Number Fax Number
Signature
►
Date
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FORM P-VOC: VERIFICATION OF COVERAGE FOR LIFE INSURANCE (Arizona)

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Completed 12 August 2020

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