A Illinois Department of Insurance Lost Policy Finder Service Form

Section 920.ILLUSTRATION A   Illinois Department of Insurance Lost Policy Finder Service Form 320 W. W a s h i n gt o n Str e e t S p ri n g f i e l d IL 62 7 67 M a i n P hon e 866 - 44 5 - 5 3 64 L oc al 21 7 - 55 7 - 6 9 55 T D D 2 17 - 52 4 - 48 7 2 i n s u r an c e .illi no i s .g o v I lli n oi s D e p a r t me n t o f I n s u r a n ce Lost Polic y Finde r Se r v ice T h e I lli noi s D ep a r t m e n t o f I n s ur a nc e c an f or w a r d a c o n s u me r ' s reque st to l oc ate a n d i den t if y i nd ivi du al lif e i n s ur a nc e po li c i e s o r a nnu i ty con t r a c ts o f a dece as e d f a m il y m e mber. W H O IS ELIGIBLE FOR THE LOST POLICY FINDER SERVICE : H O W T O S U BM IT A RE Q U E S T : Pl ea s e comp l e te a ll i n f o r ma ti o n i nd i ca t e d o n t h is f o r m , an d r e t u r n y ou r r e q ue s t in an en v e l op e ma r ke d " CO N FID E NT IAL" a l on g w ith a C O PY o f a proof of death, such as the decea s ed' s de a th ce r ti f i ca te, t o : ● An e x ecu t o r o r l ega l r ep r e s en t a tive o f a decea s e d i nd ivi dua l w h o m a y ha ve liv ed in Illi no is w he n a n i nd ivi dua l li f e i n s u r anc e po li c y o r i nd ivi dua l annu ity w a s pu r cha s ed , o r ● I nd ivi dua ls w h o ha ve r ea s o n to be li e ve t he y a r e bene f i c i a r i e s . IL D O I- L ost P ol i c y Finde r S er vi c e 320 W. Was h i n g t o n S t . S pr i n gfi e l d IL 6 2767 Y o u shou l d k ee p t h e o ri g i n al d e ath c e r t if i cat e. Insurers w i l l r e q ui r e an o r i g i n al d e ath c e r t i fi cate i n t h e e v en t t h at y o u a r e c on ta c t e d to su b m i t a c l a i m. * * * * * * * I M PO R T A N T: L if e i n s ur ers w il l r es pon d d i r e c t l y to y o u ON LY IF t h e y h a v e re as o n to be li e v e t h e dece as e d h as i nd ivi du al po li c i e s o r con t r a c ts w i th t he m A N D y o u a r e a u t h o r i z e d to r ec e iv e t h i s i n f orm at i on . * * * * ** * C O N F I D E N T I A L P E R S O N A L IN F OR M A T I O N P L E A S E WR I T E CL E A R L Y IN B L A C K O R B L U E I N K R equ e s t o r ' s N ame (P e r s o n co m p l e ti n g t h e f o rm) ( Mr. M s . Mr s . Dr., e t c .) Date o f R eque s t S tr e e t A d d r e s s City S tate Zip C o de P h o n e Nu m be r ( s ) E- mail Add r es s D e c ea s e d P e r s on ' s I n f o r m a t i on N ame o f D e c e a se d Po li c y h o l d e r o r An n ui ta n t (P l e a s e i n c l u d e all p r e vi o u s l e g al n am e s ( i. e ., mai d e n n am e )) * D e c e a sed ' s S oc ial Se cu rity N u m b e r Po li c y h o l de r/ A n nui t a n t ' s M o st R e c e n t S tr ee t A dd r ess City S tate Zip C o de Po li c y h o l de r/ A n nui t a n t ' s Pr e v i o u s S tr e e t A d d r e sses * City S tate Zip C o de Date o f B irth Date o f D e ath S tate o f P u r c h a s e * P l e a s e a tt ach se p ara t e p a g e i f m o r e s pa c e i s n e e d ed R e l a t i on s h i p o f R eque s t o r to t h e D e c ea s e d P e r s o n ( c he c k al l t ha t appl y ) Sp o us e C hi ld ( 18 o r o l de r) E xe c u t o r o r L eg al R e p r e se n ta t ive A tt o r ne y O t he r (P l e a s e spe c ify b e l ow ) □ □ □ □ □ U po n rece i p t o f t h e f u ll y comp l e t e d reque st f o r m a n d proof of death, such as a de a t h cer t ifi c ate cop y , t h e D ep a r t m e n t o f I n s ur a n c e w il l : ● F o r w a rd t h e f orm an d a tt a c h me n t s , a l on g w ith t h e proof of death , to a ll Illi no is - lic e ns e d li f e i nsurers . ● A s k t ha t t h e insurers se a r c h t h e ir r e c o r d s to d e t e r m i n e w h e t h e r t h e y ha v e an y i nd i v i du al li f e i n s u r an ce p olic i e s o r annu ity c on tr a cts in t h e na m e o f t h e d e c e a se d . ● A s k t ha t t h e insurers r es p o n d d ir e ctly to t h e r e qu es t o r on l y i f t h e y hav e an y i nd i v i du al li f e i n s u r an c e p olici e s o r annu ity c on tr a cts na m i n g t h e d e c e as e d , a n d i f t h e r e qu es t o r is au t ho ri z e d to r e c e i v e t h i s i n f or m a t i on . REQUE ST O R ' S C E R T I FI C A T I ON I c e rti f y t h at I h a v e m a d e a d ili g e n t s e arch o f t h e d e c e as e d p e r s o n 's r e c o r d s a n d p r o p e r t y , i n cl ud i n g b a n k stat e me n t s a n d sa f e ty d e p o sit b o x e s, a n d h a v e a s ke d fa m ily m e m b e rs t o i d e n tify all i nd i v i du al life p o licies o r i nd i v i du al a nnu ity c o n trac t s t h at I h a v e rea s o n t o b el i e v e c o v ered t h e life o f t h e d eceased p er s o n n a m ed a b o v e. I und e rsta n d t h at li f e i n s u r ers will r e s p on d d ir e ctly to m e onl y i f t h ey h a v e r ea s o n t o b el i e v e t h e d e c e as e d h as a n y i nd i v i du a l p o licies with t h e m an d I a m a u t h o ri z e d t o r e c e i v e t h i s i n f o r m at i o n . I und e rsta n d t h at t h e De p a r tme n t o f I n s u ra n c e 's o n l y r o le with t h is r e qu e s t is to f o r w ard to all Illi n o is lic e n s e d life i n s u rers t h is c o m p l e t e d f o r m a n d t h e proof of death .  I understand that the Department may reject this request if the Department, in its sole discretion, deems it to be incomplete, frivolous, or unduly burdensome. I und e rsta n d t h at an insurer m ay r e qu ire a dd iti o n al i n f o r m a t i o n fr o m m e , i n cl ud i n g t h e o ri g i n al d e ath c e r t ifi c ate a n d d o c um e n tat i o n o f m y l e g al a u t h o ri t y t o r e qu e st o r o b t ain i n f o r m ati o n a b o u t t h e d e c e as e d . F o r p ri v a cy a n d p r o t e ct i o n o f c o n fi d e n tial p e rs o n al l y i d e n tifia b le i n f o r m a t i o n , I und e rsta n d all o ri g i n al d o c um e n ts I s ub m it t o t h e Illi n o is D e p ar t me n t o f I n s u r a n ce will n o t b e r e t u r n e d . I f u r t h e r und e rsta n d all o r i g i n al d o c um e n ts I s ub m it with t h is r e qu e st will b e d e st r o y e d pu rs u a n t t o De p ar t me n t re t e n t i o n sc h e du l e s. I c e r t i f y t ha t t h e i n f o r m a t io n I ha v e p r ov i de d i s c o m p l e te an d a cc u r a t e . R eque s t o r' s S ig na t u r e : ______________________________________________________