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

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.

History

1. Renumbering and amendment of former section 2548.31 to new section 2548.32 filed 11-25-2014; operative 1-1-2015 (Register 2014, No. 48).