Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-97 - Life settlement regulation › Section 284-97-920 - Verification of coverage for life insurance policies form

Current through Register Vol. 24-14, July 15, 2024
RCW  48.102.110(2) provides that the request for verification
				of coverage must be made on a form approved by the commissioner. The following
				is the only verification of coverage form approved by the commissioner.
VERIFICATION OF COVERAGE FOR LIFE INSURANCE
				POLICIES
SUBMITTED TO
:
NAIC#
Name of Insurance Company
POLICY NUMBER:
SUBMITTED FROM:
Name of Life 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 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 information requested by this form by the insurance company to the life
							 settlement broker/provider.
Signature of owner
Date signed
Page 1 of 4
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 AND 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.
*
Page 2 of 4
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
Page 3 of 4
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/Life
							 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
Page 4 of 4
Statutory Authority:
				  RCW
				  48.02.060,
				  48.102.011,
				  48.102.046,
				  48.102.100,
				  48.102.170,
				  48.102.021,
				  48.102.041, and
				  48.102.080. 10-04-042 (Matter No.
				  R 2009-14), §
										284-97-920, filed 1/27/10,
				  effective 2/27/10.