Authority: IC 27-8-19.8-26

Affected: IC 27-8-19.8

Sec. 12. (a) The form for standardized viatical settlement verification of coverage for individual policies is as follows: Section Two: (To be Completed by the Life Insurance Company)

1. 1) Face amount of policy: $________
2. 2) Original date of issue: ____/____/____ (Month/Date/Year)
3. 3) Was face amount increased after original issue date?
4. ❑ no ❑ yes
5. a) If yes, when: ____/____/____ (Month/Date/Year)
6. 4) Type of Policy:________ (Term/Whole Life/Universal Life/Variable Life)
7. 5) Is policy participating? ❑ no ❑ yes
8. a) If yes, what is current dividend election?_______________
9. 6) Current net death benefit:________ (Enter full amount payable, including any additional insurance and/or dividends accumulated at interest, minus policy loans, outstanding interest on policy loans, and/or accelerated death benefits paid)
10. 7) a) Current cash value: $________ (Enter full amount, including cash value of any additional insurance and/or dividends accumulated at interest, minus policy loans and outstanding interest on policy loans)
11. b) Currently surrender value: $________
12. 8) Terms of policy loans:
13. a) Amount of policy loans: $________
14. b) Amount of outstanding interest on policy loan: $________
15. c) Current interest rate:____________________
16. 9) Has policy lapsed? ❑ no ❑ yes
17. a) If yes, when did policy lapse? ____/____/____
18. If policy has lapsed, is coverage continued under nonforfeiture option? ❑ no ❑ yes
19. If yes, indicate which option, amount of coverage, duration, etc.:_______________
20. 10) Is policy in force? ❑ no ❑ yes
21. a) If yes, has policy ever been reinstated? ❑ no ❑ yes
22. If yes, date of reinstatement: ____/____/____
23. 11) Amount of contract/scheduled premiums: $ ________
24. 12) Current premium mode: (Monthly, Semiannually, etc.)
25. d) When is next premium due? ____/____/____ (Month/Day/Year)
26. 13) Does the policy include a Disability Premium Waiver provision/rider? ❑ no ❑ yes
27. a) If yes, are premiums currently being waived?
28. ❑ no ❑ yes
29. b) If yes, since when? ____/____/____
30. c) How often is continued eligibility reviewed? ________
31. d) When is next review? ____/____/____
32. 14) Can payment of all or part of the death benefit be accelerated under this policy? ❑ no ❑ yes
33. a) If yes, by what method is the benefit calculated, the lien method or the discount method?____________________
34. b) If lien method, what is the interest rate?____________________
35. c) Can any remaining death benefit be assigned?
36. ❑ no ❑ yes
37. 15) Has a claim for Accelerated Death Benefit been submitted? ❑ no ❑ yes
38. a) If yes, was payment made under this provision?
39. ❑ no ❑ yes
40. Amount paid: ________ Date paid: __________
41. 16) Do current records show any assignments of record? ❑ no ❑ yes
42. 17) Do current records show any outstanding liens or encumbrances of record? ❑ no ❑ yes
43. 18) Please identify current primary beneficiaries: ____________________
44. e) Are they named irrevocably, or is owner otherwise limited in designation of new beneficiaries? ❑ no ❑ yes
45. 19) Have any riders been added to this policy after issue? ❑ no ❑ yes
46. If yes, please identify: _____________________
47. 20) If an ownership or beneficiary change or assignment were to be made on this policy, to whom would the completed forms be sent?

The answers provided reflect information contained in the company's records as of: (date)

(b) The form for standardized viatical settlement verification of coverage for group policies is as follows: Section Two: (To be Completed by the Employer/Group Policyholder)

1. 1) BASIC COVERAGE
2. a) Is the plan self-insured or is coverage provided under a group policy issued by a life insurance company?___________
3. If by a group policy, please provide the name of the insurance company for BASIC life insurance coverage:___________
4. b) Effective date of BASIC life insurance coverage:____________________
5. c) Face amount of BASIC life insurance:____________________
6. d) Does BASIC life insurance coverage plan have contestable provisions? ❑ no ❑ yes
7. e) Is BASIC life insurance coverage subject to a suicide provision? ❑ no ❑ yes
8. f) Monthly premium paid by employer/group policyholder for BASIC life insurance coverage: $___________
9. g) Monthly premium paid by employee/insured for BASIC life insurance coverage: $___________
10. h) Is BASIC life insurance coverage ❑ Term ❑ Universal Life?
11. I) If Universal Life, please indicate cash value, if any:____________________
12. Is this amount payable in addition to the face amount? ❑ no ❑ yes
13. i) Is coverage in force? ❑ no ❑ yes
14. j) When is next premium due?____________________

15. k) Has employee's coverage under this plan ever been reinstated? ❑ no ❑ yes

    1. I) If yes, date of reinstatement:____________________
    2. 2) SUPPLEMENTAL (OPTIONAL) COVERAGE
    3. a) Insurance Company for SUPPLEMENTAL life insurance coverage:____________________
    4. b) Effective date of SUPPLEMENTAL life insurance coverage:____________________
    5. c) Face amount of SUPPLEMENTAL life insurance:____________________
    6. d) Does SUPPLEMENTAL life insurance coverage plan have contestable provisions? ❑ no ❑ yes
    7. e) Is SUPPLEMENTAL life insurance coverage subject to a suicide provision? ❑ no ❑ yes
    8. f) Monthly premium paid by employer/group policyholder for SUPPLEMENTAL life insurance: $____________
    9. g) Monthly premium paid by employee/insured for SUPPLEMENTAL life insurance: $____________
    10. h) Is SUPPLEMENTAL life insurance coverage ❑ Term ❑ Universal Life?
    11. I) If Universal Life, please indicate cash value, if any:____________________
    12. Is this amount payable in addition to the face amount? ❑ no ❑ yes
    13. i) Is coverage in force? ❑ no ❑ yes
    14. j) When is next premium due?____________________
    15. I) Has employee's coverage under this policy ever been reinstated? ❑ no ❑ yes
    16. k) If yes, date of reinstatement:____________________
    17. 3) DISABILITY WAIVER OF PREMIUM
    18. a) Does plan provide for waiver of premium in the event of employee/insured's disability?
    19. BASIC: ❑ no ❑ yes What is the waiting period?____________________
    20. SUPPLEMENTAL: ❑ no ❑ yes What is the waiting period?____________________
    21. b) Are premiums currently being waived under disability premium waiver?
    22. BASIC: ❑ no ❑ yes
    23. SUPPLEMENTAL: ❑ no ❑ yes
    24. c) Who pays premiums under disability premium waiver?
    25. BASIC: ❑ Insurance carrier ❑ Employer
    26. SUPPLEMENTAL: ❑ Insurance carrier ❑ Employer
    27. d) What was the date of approval?____________________
    28. e) Next review date?____________________
    29. f) If the insured is no longer eligible for waiver, what amount of coverage can be converted to an individual policy? $________
    30. I) Will a new suicide/contestability clause be in effect for the converted policy? ❑ no ❑ yes
    31. II) Will assignee be notified if insured is no longer eligible for waiver? ❑ no ❑ yes
    32. 4) BENEFICIARIES, ASSIGNMENTS, AND LIMITATIONS
    33. a) Who are the primary beneficiaries of the coverage(s)?
    34. BASIC: _________________________
    35. SUPPLEMENTAL: ______________
    36. b) Is any beneficiary under this policy designated irrevocably, or is insured otherwise limited in designation of new beneficiaries? ❑ no ❑ yes
    37. c) Can this coverage be assigned?
    38. BASIC: ❑ no ❑ yes
16. If yes, to a corporation? ❑ no ❑ yes
17. To someone not related to insured? ❑ no ❑ yes
18. SUPPLEMENTAL: ❑ no ❑ yes
19. If yes, to a corporation? ❑ no ❑ yes
20. To someone not related to insured? ❑ no ❑ yes
21. d) Do records show any assignments of record?
22. ❑ no ❑ yes
23. e) Do records show any outstanding liens or encumbrances of record? ❑ no ❑ yes
24. f) Will an Assignee be notified if the master policy is canceled? ❑ no ❑ yes
25. g) Can Assignee convert the coverage without the permission of insured? ❑ no ❑ yes
26. 5) ACCELERATED DEATH BENEFITS
27. a) Is there an Accelerated Death Benefit available under the coverage?
28. BASIC: ❑ no ❑ yes
29. SUPPLEMENTAL: ❑ no ❑ yes
30. b) Has request for Accelerated Death Benefit been made? ❑ no ❑ yes
31. c) Has payment been made to insured under this provision? ❑ no ❑ yes
32. I) Amount paid: ________ Date paid:____________________
33. II) Is this amount a lien against death proceeds?
34. ❑ no ❑ yes
35. Interest rate_____
36. III) Can the remaining death benefit be assigned?
37. ❑ no ❑ yes
38. 6) MISCELLANEOUS
39. a) Is coverage portable?
40. BASIC: ❑ no ❑ yes
41. SUPPLEMENTAL: ❑ no ❑ yes
42. b) If insured is no longer eligible for coverage under the group, will Assignee be notified? ❑ no ❑ yes
43. c) If master policy discontinues, what amount can be converted to an individual policy?_____
44. d) Is this plan administered by a third party? ❑ no ❑ yes
45. If yes, please provide the name, address, and telephone number of administrator:

If a change of beneficiary form or assignment were to be made for this coverage, to whom should the completed forms be sent? The answers provided reflect information in our files as of ______ (date). Information not provided by the employer may be obtained from the insurance company if different from administrator identified above: Section Three: The insurance company or the third party administrator named above is requested to complete the information not provided by the employer in Section Two, above, Items number: _____________. The answers provided to the identified questions reflect information in the files of the insurance company as of ________ (date).

(Department of Insurance; 760 IAC 1-61-12; filed Oct 20, 1999, 10:23 a.m.: 23 IR 584; readopted filed Nov 7, 2005, 10:50 a.m.: 29 IR 896; readopted filed Nov 29, 2011, 9:14 a.m.: 20111228-IR-760110553RFA; readopted filed Nov 6, 2017, 1:06 p.m.: 20171206-IR-760170354RFA; readopted filed Nov 13, 2023, 10:12 a.m.: 20231213-IR-760230631RFA)