Illinois Administrative Code › Title 50 - INSURANCE › Part 920 - IMPROPER CLAIMS PRACTICE › ILLUSTRATION A - Illinois Department of Insurance Lost Policy Finder Service Form

Current through Register Vol. 48, No. 28, July 12, 2024
320 W. Washington Street
Springfield IL 62767
Main Phone
866-445-5364
Local
217-557-6955
TDD
217-524-4872
insurance.illinois.gov
Illinois Department of
				Insurance
Lost Policy Finder Service
The Illinois Department of Insurance can forward a
				consumer's request to locate and identify individual life insurance policies or
				annuity contracts of a deceased family member.
WHO IS ELIGIBLE FOR THE
						  LOST POLICY FINDER SERVICE:
HOW TO SUBMIT A
						  REQUEST:
* An executor or legal representative of a
						  deceased individual who may have lived in Illinois when an individual life
						  insurance policy or individual annuity was purchased,
						  or
Please complete all information indicated on
						  this form, and return your request in an envelope marked "CONFIDENTIAL" along
						  with a
COPY
of a proof of death, such as the deceased's death
						  certificate, to:
* Individuals who have reason to believe they
						  are beneficiaries.
IL DOI-Lost Policy Finder Service 320
						  W. Washington St. Springfield IL 62767
You should keep the original death certificate.
						  Insurers will require an original death certificate in the event that you are
						  contacted to submit a claim.
*******IMPORTANT: Life insurers will
				respond directly to you ONLY IF they have reason to believe the deceased has
				individual policies or contracts with them AND you are authorized to receive
				this information.*******
CONFIDENTIAL PERSONAL
				INFORMATION
PLEASE WRITE CLEARLY IN BLACK OR
				BLUE INK
Requestor's Name (Person completing the form) (Mr. Ms.
						  Mrs. Dr., etc.)
Date of Request
Street Address
City
State
Zip Code
Phone Number(s)
E-mail Address
Deceased Person's
				Information
Name of Deceased Policyholder or Annuitant (Please
						  include all previous legal names (i.e., maiden name))*
Deceased's Social Security Number
Policyholder/Annuitant's
Most Recent
Street Address
City
State
Zip Code
Policyholder/Annuitant's
Previous
Street Addresses*
City
State
Zip Code
Date of Birth
Date of Death
State of Purchase
*Please attach separate page if more space is
				needed
Relationship of Requestor to the Deceased
				Person (check all that apply)
Spouse
Child (18 or older)
Executor or Legal Representative
Attorney
Other (Please specify below)
[]
[]
[]
[]
[]
Upon receipt of the fully completed request
				form and proof of death, such as a death certificate copy, the Department of
				Insurance will:
* Forward the form and attachments, along with the
				proof of death, to all Illinois-licensed life insurers.
* Ask that the insurers search their records to
				determine whether they have any individual life insurance policies or annuity
				contracts in the name of the deceased.
* Ask that the insurers respond directly to the
				requestor
only if
they have any individual life insurance policies
				or annuity contracts naming the deceased,
and if
the requestor is
				authorized to receive this information.
REQUESTOR'S CERTIFICATION
I certify that I have made a diligent search of the deceased
				person's records and property, including bank statements and safety deposit
				boxes, and have asked family members to identify all individual life policies
				or individual annuity contracts that I have reason to believe covered the life
				of the deceased person named above. I understand that life insurers will
				respond directly to me
only if
they have reason to believe the
				deceased has any individual policies with them
and
I am authorized
				to receive this information.
I understand that the Department of Insurance's only role with
				this request is to forward to all Illinois licensed life insurers this
				completed form and the proof of death. I understand that the Department may
				reject this request if the Department, in its sole discretion, deems it to be
				incomplete, frivolous, or unduly burdensome. I understand that an insurer may
				require additional information from me, including the original death
				certificate and documentation of my legal authority to request or obtain
				information about the deceased.
For privacy and protection of confidential personally
				identifiable information, I understand all original documents I submit to the
				Illinois Department of Insurance will not be returned. I further understand all
				original documents I submit with this request will be destroyed pursuant to
				Department retention schedules.
I certify that the information I have provided is
				complete and accurate.
Requestor's Signature:
				__________________________________________________