California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 3 - Insurers › Article 12.9 - Life Settlements › Section 2548.32 - Verification of Coverage for Life Insurance Policies

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
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
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).
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.