Cal. Code Regs. tit. 10 § 2548.32
VERIFICATION OF COVERAGE FOR LIFE INSURANCE POLICIES
SUBMITTED TO: ____________________Name of Insurance Company NAIC #_______________
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 |
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. | * | |
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 accurate to the best of my knowledge and has been obtained through the policy owner and/or insured.
| ___________________________ | ___________________________ | ||
| Signature | Printed Name |
TO BE COMPLETED BY INSURANCE COMPANY
The information provided by verification by the insurance company is correct 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:
* Absolute Assignment/Change of Ownership/Viatical Assignment
* Change of Beneficiary
* Release of Irrevocable Beneficiary (if applicable)
* Waiver of Premium Claim Form
* Disability Waiver of Premium Approval Letter
* Release of Assignment
* Change of Death Benefit Option Form (if UL)
* Allocation Change Form (if Variable)
* Annual Report
* Current In Force Illustration
Cal. Code Regs. Tit. 10, § 2548.32
Note: Authority cited: Section 10113.35, Insurance Code; CalFarm Ins. Co. v. Deukmejian, 48 Cal.3d 805 (1989); 20th Century Ins. Co. v. Garamendi, 8 Cal.4th 216 (1994). Reference: Sections 10113.2 and 10113.3, Insurance Code.