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

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.

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

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.

*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.

*

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?

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

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:

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