Ill. Admin. Code tit. 50, pt. 3701, exh. H
VERIFICATION OF COVERAGE FOR LIFE INSURANCE POLICIES
SUBMITTED TO: ___________________________________________ NAIC # _________________
Name of Insurance Company
POLICY NUMBER: ____________________________________________________
SUBMITTED FROM: ___________________________________________________
Name of Viatical Settlement Broker/Provider
ADDRESS: __________________________________________________________
TELEPHONE NUMBER: ________________________________________________
CONTACT: ______________________________ TITLE: ___________________
IF INFORMATION IS CORRECT, INSURER REPRESENTATIVE MAY PLACE A CHECKMARK IN THE BOX. OTHERWISE, PROVIDE CORRECTED INFORMATION THROUGHOUT THIS FORM. AN ASTERISK INDICATES INFORMATION THE VIATICAL SETTLEMENT PROVIDER/BROKER MUST PROVIDE.
POLICY OWNER'S AND INSURED'S INFORMATION
This column to be completed by Viatical 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 viatical settlement broker/provider.
______________________________________________________________________
Signature of policy ownerDate signed
Form VOC
IS THE POLICY IN FORCE?______ YES______ NO
IF NO, SIGN AND DATE ON PAGE 4 AND RETURN TO THE VIATICAL SETTLEMENT BROKER OR PROVIDER THAT SUBMITTED THE VERIFICATION OF COVERAGE.
* ______ 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 Viatical 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 Viatical 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 Viatical 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 VIATICAL SETTLEMENT BROKER/PROVIDER
The information submitted for verification by the viatical settlement broker/provider is correct and accurate to the best of my knowledge and has been obtained through the policy owner and/or insured.
__________________________________________
SignaturePrinted Named
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
Ill. Admin. Code tit. 50, pt. 3701, exh. H