760 IAC 1-61-12 Insurance coverage verification forms

Sec. 12. (a) The form for standardized viatical settlement verification of coverage for individual policies is as follows: VERIFICATION OF COVERAGE FOR INDIVIDUAL POLICIES Section One: (To be Completed by the Viatical Settlement Provider, Broker, or Agent) Insurance Company: Name of Policyowner: Policy Number: Owner's Social Security Number: Name of Insured: Policyowner's Address: Insured's date of birth: Street City/State Please provide the information requested in Section Two (below) with regard to the policy identified above and in accordance with the attached authorization. In addition, please provide the forms checked below which are available from your company to complete a viatical settlement transaction: ❑ Absolute Assignment/Change of Ownership/Viatical Assignment Form ❑ Change of Beneficiary ❑ Release of Irrevocable Beneficiary (if applicable) ❑ Waiver of Premium Claim Form ❑ Disability Waiver of Premium Approval Letter Date Signature of a representative of Viatical Settlement Provider, Broker, or Agent Full name and address of Viatical Settlement Provider, Broker, or Agent Section Two: (To be Completed by the Life Insurance Company) 1) Face amount of policy: $________ 2) Original date of issue: ____/____/____ (Month/Date/Year) 3) Was face amount increased after original issue date? ❑ no ❑ yes a) If yes, when: ____/____/____ (Month/Date/Year) 4) Type of Policy:________ (Term/Whole Life/Universal Life/Variable Life) 5) Is policy participating? ❑ no ❑ yes a) If yes, what is current dividend election?_______________ 6) Current net death benefit:________ (Enter full amount payable, including any additional insurance and/or dividends accumulated at interest, minus policy loans, outstanding interest on policy loans, and/or accelerated death benefits paid) 7) a) Current cash value: $________ (Enter full amount, including cash value of any additional insurance and/or dividends accumulated at interest, minus policy loans and outstanding interest on policy loans) b) Currently surrender value: $________ 8) Terms of policy loans: a) Amount of policy loans: $________ b) Amount of outstanding interest on policy loan: $________ c) Current interest rate:____________________ 9) Has policy lapsed? ❑ no ❑ yes a) If yes, when did policy lapse? ____/____/____ If policy has lapsed, is coverage continued under nonforfeiture option? ❑ no ❑ yes If yes, indicate which option, amount of coverage, duration, etc.:_______________ 10) Is policy in force? ❑ no ❑ yes a) If yes, has policy ever been reinstated? ❑ no ❑ yes If yes, date of reinstatement: ____/____/____ 11) Amount of contract/scheduled premiums: $ ________ 12) Current premium mode: (Monthly, Semiannually, etc.) d) When is next premium due? ____/____/____ (Month/Day/Year) 13) Does the policy include a Disability Premium Waiver provision/rider? ❑ no ❑ yes a) If yes, are premiums currently being waived? ❑ no ❑ yes b) If yes, since when? ____/____/____ c) How often is continued eligibility reviewed? ________ d) When is next review? ____/____/____ 14) Can payment of all or part of the death benefit be accelerated under this policy? ❑ no ❑ yes a) If yes, by what method is the benefit calculated, the lien method or the discount method?____________________ b) If lien method, what is the interest rate?____________________ c) Can any remaining death benefit be assigned? ❑ no ❑ yes 15) Has a claim for Accelerated Death Benefit been submitted? ❑ no ❑ yes a) If yes, was payment made under this provision? ❑ no ❑ yes Amount paid: ________ Date paid: __________ 16) Do current records show any assignments of record? ❑ no ❑ yes 17) Do current records show any outstanding liens or encumbrances of record? ❑ no ❑ yes 18) Please identify current primary beneficiaries: ____________________ e) Are they named irrevocably, or is owner otherwise limited in designation of new beneficiaries? ❑ no ❑ yes 19) Have any riders been added to this policy after issue? ❑ no ❑ yes If yes, please identify: _____________________ 20) If an ownership or beneficiary change or assignment were to be made on this policy, to whom would the completed forms be sent? Name: Title: Company Name: Department: Address (No P.O. Box, please): City: ST: ZIP: Telephone Number: Fax Number: The answers provided reflect information contained in the company's records as of: (date) Signature: Name (Printed): Title: Company: Direct Telephone Number: Direct Fax Number: (b) The form for standardized viatical settlement verification of coverage for group policies is as follows: VERIFICATION OF GROUP LIFE INSURANCE BENEFITS Section One: (To be Completed by the Viatical Settlement Provider, Broker, or Agent) Insurance Company Name of Employee/Member Employer/Policyholder Name Insured's Date of Birth Policy Number Insured's Social Security Number Certificate Number Employee/Membership Number Please provide the information requested in Section Two or Section Three, as appropriate, with regard to the individual and coverage described, in accordance with the attached authorization. In addition, please provide the forms checked below which are available from your company to complete a viatical settlement transaction: Absolute Assignment ❑ Change of Beneficiary (irrevocable if applicable) ❑ Disability Waiver of premium claim or ❑ Disability Waiver of premium award letter Date Signature of a representative of Viatical Settlement Provider, Broker, or Agent Full name and address of Viatical Settlement Provider, Broker, or Agent Section Two: (To be Completed by the Employer/Group Policyholder) 1) BASIC COVERAGE a) Is the plan self-insured or is coverage provided under a group policy issued by a life insurance company?___________ If by a group policy, please provide the name of the insurance company for BASIC life insurance coverage:___________ b) Effective date of BASIC life insurance coverage:____________________ c) Face amount of BASIC life insurance:____________________ d) Does BASIC life insurance coverage plan have contestable provisions? ❑ no ❑ yes e) Is BASIC life insurance coverage subject to a suicide provision? ❑ no ❑ yes f) Monthly premium paid by employer/group policyholder for BASIC life insurance coverage: $___________ g) Monthly premium paid by employee/insured for BASIC life insurance coverage: $___________ h) Is BASIC life insurance coverage ❑ Term ❑ Universal Life? I) If Universal Life, please indicate cash value, if any:____________________ Is this amount payable in addition to the face amount? ❑ no ❑ yes i) Is coverage in force? ❑ no ❑ yes j) When is next premium due?____________________ k) Has employee's coverage under this plan ever been reinstated? ❑ no ❑ yes I) If yes, date of reinstatement:____________________ 2) SUPPLEMENTAL (OPTIONAL) COVERAGE a) Insurance Company for SUPPLEMENTAL life insurance coverage:____________________ b) Effective date of SUPPLEMENTAL life insurance coverage:____________________ c) Face amount of SUPPLEMENTAL life insurance:____________________ d) Does SUPPLEMENTAL life insurance coverage plan have contestable provisions? ❑ no ❑ yes e) Is SUPPLEMENTAL life insurance coverage subject to a suicide provision? ❑ no ❑ yes f) Monthly premium paid by employer/group policyholder for SUPPLEMENTAL life insurance: $____________ g) Monthly premium paid by employee/insured for SUPPLEMENTAL life insurance: $____________ h) Is SUPPLEMENTAL life insurance coverage ❑ Term ❑ Universal Life? I) If Universal Life, please indicate cash value, if any:____________________ Is this amount payable in addition to the face amount? ❑ no ❑ yes i) Is coverage in force? ❑ no ❑ yes j) When is next premium due?____________________ I) Has employee's coverage under this policy ever been reinstated? ❑ no ❑ yes k) If yes, date of reinstatement:____________________ 3) DISABILITY WAIVER OF PREMIUM a) Does plan provide for waiver of premium in the event of employee/insured's disability? BASIC: ❑ no ❑ yes What is the waiting period?____________________ SUPPLEMENTAL: ❑ no ❑ yes What is the waiting period?____________________ b) Are premiums currently being waived under disability premium waiver? BASIC: ❑ no ❑ yes SUPPLEMENTAL: ❑ no ❑ yes c) Who pays premiums under disability premium waiver? BASIC: ❑ Insurance carrier ❑ Employer SUPPLEMENTAL: ❑ Insurance carrier ❑ Employer d) What was the date of approval?____________________ e) Next review date?____________________ f) If the insured is no longer eligible for waiver, what amount of coverage can be converted to an individual policy? $________ I) Will a new suicide/contestability clause be in effect for the converted policy? ❑ no ❑ yes II) Will assignee be notified if insured is no longer eligible for waiver? ❑ no ❑ yes 4) BENEFICIARIES, ASSIGNMENTS, AND LIMITATIONS a) Who are the primary beneficiaries of the coverage(s)? BASIC: _________________________ SUPPLEMENTAL: ______________ b) Is any beneficiary under this policy designated irrevocably, or is insured otherwise limited in designation of new beneficiaries? ❑ no ❑ yes c) Can this coverage be assigned? BASIC: ❑ no ❑ yes If yes, to a corporation? ❑ no ❑ yes To someone not related to insured? ❑ no ❑ yes SUPPLEMENTAL: ❑ no ❑ yes If yes, to a corporation? ❑ no ❑ yes To someone not related to insured? ❑ no ❑ yes d) Do records show any assignments of record? ❑ no ❑ yes e) Do records show any outstanding liens or encumbrances of record? ❑ no ❑ yes f) Will an Assignee be notified if the master policy is canceled? ❑ no ❑ yes g) Can Assignee convert the coverage without the permission of insured? ❑ no ❑ yes 5) ACCELERATED DEATH BENEFITS a) Is there an Accelerated Death Benefit available under the coverage? BASIC: ❑ no ❑ yes SUPPLEMENTAL: ❑ no ❑ yes b) Has request for Accelerated Death Benefit been made? ❑ no ❑ yes c) Has payment been made to insured under this provision? ❑ no ❑ yes I) Amount paid: ________ Date paid:____________________ II) Is this amount a lien against death proceeds? ❑ no ❑ yes Interest rate_____ III) Can the remaining death benefit be assigned? ❑ no ❑ yes 6) MISCELLANEOUS a) Is coverage portable? BASIC: ❑ no ❑ yes SUPPLEMENTAL: ❑ no ❑ yes b) If insured is no longer eligible for coverage under the group, will Assignee be notified? ❑ no ❑ yes c) If master policy discontinues, what amount can be converted to an individual policy?_____ d) Is this plan administered by a third party? ❑ no ❑ yes If yes, please provide the name, address, and telephone number of administrator: Name: Title: Company Name: Department: Street Address (No P.O. Box, please): City: State: Zip: Telephone Number: Fax: If a change of beneficiary form or assignment were to be made for this coverage, to whom should the completed forms be sent? Name: Title: Company Name: Department: Street Address (No P.O. Box, please): City: State: Zip: Telephone Number: Fax: The answers provided reflect information in our files as of ______ (date). Signature: Name: Date: Title: Company: Direct Telephone Number: Direct Fax Number: Information not provided by the employer may be obtained from the insurance company if different from administrator identified above: Name: Title: Company Name: Department: Street Address (No P.O. Box, please): City: State: Zip: Telephone Number: Fax: Section Three: The insurance company or the third party administrator named above is requested to complete the information not provided by the employer in Section Two, above, Items number: _____________. The answers provided to the identified questions reflect information in the files of the insurance company as of ________ (date). Signature: Name: Date: >Title: Company: Telephone Number: Fax Number: