Fillable VERIFICATION OF COVERAGE FOR LIFE INSURANCE POLICIES Name (California)

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VERIFICATION OF COVERAGE FOR LIFE INSURANCE POLICIES Name (California)

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The VERIFICATION OF COVERAGE FOR LIFE INSURANCE POLICIES Name (California) form is 4 pages long and contains:

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  • 0 check-boxes
  • 129 other fields

Country of origin: US
File type: PDF

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__________________________________________ ________________________
VERIFICATION OF COVERAGE FOR LIFE INSURANCE POLICIES
SUBMITTED TO: __________________________________________NAIC #_________________
Name of Insurance Company
POLICY NUMBER: _______________________________________________________________
SUBMITTED FROM: _______________________________________________________________
Name of Life Settlement Broker
/Provider
ADDRESS: ________________________________________________________________________
TELEPHONE NUMBER: ____________________________________________________________
CONTACT: __________________________________TITLE:____________________________
IF INFORMATION IS CORRECT, INSURER REPRESENTATIVE MAY PLACE A CHECK MARK IN THE
BOX. OTHERWISE PROVIDE CORRECTED INFORMATION THROUGHOUT THIS FORM. AN
ASTERISK INDICATES INFORMATION THE LIFE SETTLEMENT PROVIDER/BROKER MUST
PROVIDE.
POLICY OWNER’S AND INSURED’S INFORMATION
This column to be completed by
Life Settlement Broker/Provider
This column to be used by
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)
*
I hereby consent by my signature below to release of information requested by this form by the
insurance company to the life settlement broker/provider.
Signature of policy owner Date signed
Page 1 of 4
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signature
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IS THE POLICY IN FORCE? ____YES ____NO
IF NO, SIGN, AND DATE ON PAGE 4 AND RETURN TO THE LIFE SETTLEMENT BROKER OR
PROVIDER THAT SUBMITTED THE VERIFICATION OF COVERAGE.
POLICY TYPE, RIDERS & OPTIONS:
*
_____TERM _____WHOLE LIFE _____UNIVERSAL LIFE _____VARIABLE LIFE
If a question is not applicable to the type of policy, write N/A in the column.
This column to be completed by
Life Settlement Broker/Provider
This column to be used by
Insurance Company
Original issue date
*
Maturity date of policy
State of issue
*
Does the policy have an
irrevocable beneficiary?
*
Is the policy currently
assigned?
*
Was the policy ever
converted or reinstated?
Is the policy in the
contestability period?
*
Is the policy in the suicide
period?
*
Please list all riders and
indicate if any are in the
contestable or suicide
period.
*
Page 2 of 4
______________________________________ ________________________________
POLICY VALUES
This column to be completed
by Life Settlement
Broker/Provider
This column to be used by
Insurance Company
Policy values as of (insert 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?
PREMIUM INFORMATION
This column to be completed
by Life Settlement
Broker/Provider
This column to be used by
Insurance Company
Current payment mode
*
Current modal premium
*
Date last premium paid
*
Date next premium due
*
Current monthly cost of insurance
as of (insert date)
Date of last cost of insurance
deduction
TO BE COMPLETED BY LIFE SETTLEMENT BROKER/PROVIDER
The information submitted for verification by the life settlement broker/provider is correct and accu rate
to the best of my knowledge and has been obtained through the policy owner and/or insured.
Signature Printed Name
Page 3 of 4
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signature
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TO BE COMPLETED BY INSURANCE COMPANY
The information provided by verification by the insu rance company is co rrect and accurate to the best of
my knowledge as of _____________________(date).
Insurance company: ____________________________________________NAIC #________________
Printed name: _______________________________________Title: ___________________________
Telephone number: (___ )________________________Fax number: (___)_______________________
Signature: __________________________________________________________________________
Please provide information about where the forms listed below should be submitted for processing.
Name: _____________________________________________Title: __________________________
Company Name: ____________________________________________________________________
Mailing Address: ____________________________________________________________________
City, State, ZIP: _____________________________________________________________________
Overnight Address: __________________________________________________________________
City, State, ZIP: _____________________________________________________________________
Telephone number: (___ )________________________Fax number: (___ )_______________________
FORMS REQUEST
Please provide the forms checked below:
o Absolute Assignment/Change of Ownership/Viatical
Assignment
o Change of Beneficiary
o Release of Irrevocable Beneficiary (if applicable)
o Waiver of Premium Claim Form
o Disability Waiver of Premium Approval Letter
o Release of Assignment
o Change of Death Benefit Option Form (if UL)
o Allocation Change Form (if Variable)
o Annual Report
o Current In Force Illustration
Page 4 of 4
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VERIFICATION OF COVERAGE FOR LIFE INSURANCE POLICIES Name (California)

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Completed 8 March 2021

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