Appendix C- Verification of Group Insurance Benefits

Appendix C- Verification of Group Insurance Benefits APPENDIX C VERIFICATION OF GROUP LIFE INSURANCE BENEFITS ______________________________________________________________________________ Section One: (To be completed by the viatical settlement provider or viatical settlement broker) 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 ViaticalSettlement Broker or Viatical Settlement Provider Full name and address of Viatical Settlement Broker or Viatical Settlement Provider ______________________________________________________________________________ Section Two: (To be completed by the employer/group policyholder and the insurer. Both should indicate the parts they completed) 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 coverage plan have contestable provisions? no yes e) Is BASIC coverage subject to a suicide provision? no yes f) Monthly premium paid by employer/group policyholder for BASIC life insurance: $ g) Monthly premium paid by employee/insured for BASIC life insurance: $ 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 coverage plan have contestable provisions? no yes e) Is SUPPLEMENTAL 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? k) Has employee’s coverage under this policy been reinstated within the last two years? no yes i) 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) The following parties (as applicable) should indicate whether they will provide notice to the assignee if the master policy is terminated. Group policyholder no yes Third party administrator (if any) no yes Insurance Company 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 If master policy discontinues, what amount can be converted to an individual policy? $ 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 above: Name_ ____________________________________ Title____________________________ Company name:_____________________________ Department______________________ Street Address:________________________________________________________________ (No P.O. Box please) City:____________________________________State____________ZIP_________________ Telephone number: (___) ____________________ Fax: (___)_____________________ ____________________________________________________________________________ Section Three: Under the terms of Mississippi Regulation 2000-1 covering insurance company practices, 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:___________________________________________________ Direct telephone number:(___)____________Direct fax number: ( )_________________