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

PDFWAC 284-97-920

Verification of coverage for life insurance policies form.