Appendix B- Verification of Coverage for Individual Policies

Appendix B- Verification of Coverage for Individual Policies APPENDIX B VERIFICATION OF COVERAGE FOR INDIVIDUAL POLICIES Section One: (To be completed by the Viatical Settlement Provider or Viatical Settlement Broker) Insurance Company:_________________Name of Policyowner ________________________ Policy number: _________________ Owner’s Social Security Number: __________________ Name of Insured: ___________________ Policyowner’s Address: ______________________ (street) Insured’s date of birth: _______________ ________________________________________ (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 Broker or Viatical Settlement Provider ______________________________________________________________________________ ______________________________________________________________________________ Full name and address of Viatical Settlement Broker or Viatical Settlement Provider ______________________________________________________________________________ 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: _______/_________/________ 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) Current 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 non-forfeiture option? no yes If yes, indicate which option, amount of coverage, duration, etc.:_________________ 10) Is policy in force? no yes a) If yes, has the policy been reinstated within the last two years? no yes If yes, date of reinstatement: ________/________/__________ 11) Amount of contract/scheduled premiums: $____________________________ 12) Current premium mode: ______________________________(Monthly, semi-annually, etc.) a) 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: ________________________________ a) 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:___________________________________Department:______________________ Address(no PO BOX, please) __________________________________________________ City:__________________________________State:_________________ZIP:_____________ Telephone No: _________________________________ Fax: __________________________ The answers provided reflect information contained in the company’s records as of:__________ (date) Signature: __________________________________Name (printed)_______________________ Title:_________________________________________________________________________ Company: _____________________________________________________________________ Direct Telephone No: __________________________Direct Fax No:_____________________