WAC 284-97-920

Verification of coverage for life insurance policies form.

RCW 48.102.110(2) provides that the request for verification of coverage must be made on a form approved by the commissioner. The following is the only verification of coverage form approved by the commissioner.
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 CHECKMARK 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 information requested by this form by the insurance company to the life settlement broker/provider.
Signature of owner
 
Date signed
Page 1 of 4
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 and 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 accurate to the best of my knowledge and has been obtained through the policy owner and/or insured.
 
 
 
Signature
 
Printed name
Page 3 of 4
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/Life 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
Page 4 of 4
[Statutory Authority: RCW 48.02.060, 48.102.011, 48.102.046, 48.102.100, 48.102.170, 48.102.021, 48.102.041, and 48.102.080. WSR 10-04-042 (Matter No. R 2009-14), § 284-97-920, filed 1/27/10, effective 2/27/10.]