Illinois Administrative Code › Title 50 - INSURANCE › Part 3701 - VIATICAL SETTLEMENT PROVIDER AND BROKER REQUIREMENTS › Exhibit H - Verification of Coverage for Life Insurance Policies

Current through Register Vol. 48, No. 28, July 12, 2024
VERIFICATION OF COVERAGE FOR LIFE INSURANCE
				POLICIES
SUBMITTED TO: ___________________________________________ NAIC
				# _________________
Name of Insurance Company
POLICY NUMBER:
				____________________________________________________
SUBMITTED FROM:
				___________________________________________________
Name of Viatical 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 VIATICAL SETTLEMENT PROVIDER/BROKER
				MUST PROVIDE.
POLICY OWNER'S AND INSURED'S INFORMATION
This column to be completed by Viatical 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 viatical
				settlement broker/provider.
______________________________________________________________________
Signature of policy
				ownerDate
				signed
Form VOC
IS THE POLICY IN FORCE?______
				YES______ NO
IF NO, SIGN AND DATE ON PAGE 4 AND RETURN TO THE
				VIATICAL SETTLEMENT BROKER OR PROVIDER THAT SUBMITTED THE VERIFICATION OF
				COVERAGE.
* ______ 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 Viatical
						  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 Viatical
						  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 Viatical
						  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 VIATICAL SETTLEMENT
				BROKER/PROVIDER
The information submitted for verification by the viatical
				settlement broker/provider is correct and accurate to the best of my knowledge
				and has been obtained through the policy owner and/or insured.
__________________________________________
SignaturePrinted
				Named
Click here to view
				image
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