H Verification of Coverage for Life Insurance Policies

Section 3701.EXHIBIT H   Verification of Coverage for Life Insurance Policies 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 owner Date signed Form VOC Page 1 of 4 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. * Page 2 of 4 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. Signature Printed Named 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/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 Page 4 of 4