VIGENCIA

Las disposiciones de esta Regla entrarán en vigor treinta (30) días después de su presentación en el Departamento de Estado, de acuerdo con las disposiciones de la Ley Núm. 170, supra. RAMÓN L. CRUZ COLÓN COMISIONADO DE SEGUROS Fecha de aprobación: 18ENE 2012 Fecha de Radicación en el Departamento de Estado: Fecha de Radicación en la Biblioteca Legislativa: 11 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 This column to be used by Viatical Settlement Insurance Company Broker/Provider 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 Page 1 of 4 Form VOC © 2004 National Association of Insurance Commissioners 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. POLICY TYPE, RIDERS & OPTIONS: * 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 This column to be used by Broker/Provider 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 c 2004 National Association of Insurance Commissioners POLICY VALUES This column to be completed by Viatical Settlement This column to be used by Broker/Provider 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 This column to be used by Broker/Provider 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 insured. accurate to the best of my knowledge and has been obtained through the policy owner and/or Signature Printed Name Page 3 of 4 © 2004 National Association of Insurance Commissioners 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 © 2004 National Association of Insurance Commissioners Viatical Settlement Provider Report-All States and Territories Instructions NOTE: This form must be accompanied by Viatical Settlement Provider / Broker Certification Form. Indicate (Y or N); have you done business in this state during the calendar year being 1. reported. 2. For that state or territory, indicate the total number of policies reviewed for consideration for that state or territory. 3. For that state or territory, indicate the total number of policies where an offer was made. 4. For that state or territory, indicate the total number of policies where an offer was refused. 5. For that state or territory, indicate the total number of policies purchased. 6. List the total aggregate net death benefit of the policies viaticated in that state or territory. 7. List the total aggregate amount paid to viators in that state or territory. List the total number of policies purchased and/or sold in the secondary market for that 8. state or territory. VSP 001 Instructions Initials of preparer: © 2004 National Association of Insurance Commissioners Viatical Settlement Provider Report Calendar year Viatical Settlement Provider's Name All States and Territories 20 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 States Are you doing business in this state? (Y/N) Total number of policies reviewed for consideration Total number of policies where an offer was made Total number of policies where an offer was not made Total number of policies purchased Aggregate total net death benefit Aggregate amount paid to viators Secondary market transactions States Are you doing business in this state? (Y/N) Total number of policies reviewed for consideration Total number of policies where an offer was made Total number of policies where an offer was not made Total number of policies purchased Aggregate total net death benefit Aggregate amount paid to viators Secondary market transactions pur sold pur sold Alabama New Jersey Alaska New Mexico Arizona New York Arkansas North Carolina California North Dakota Colorado Ohio Connecticut Oklahoma Delaware Oregon Dist. of Columbia Pennsylvania Florida Rhode Island Georgia South Carolina Hawaii South Dakota Idaho Tennessee Illinois Texas © 2004 National Association of Insurance Commissioners Indiana Utah lowa Vermont Kansas Virginia Kentucky Washington Loulsiana West Virginia Maine Wisconsin Maryland Wyoming Massachusetts American Samoa Michigan Guam Minnesota Puerto Rico Mississippi U.S Virgin Islands Missouri Canada Montana Nebraska TOTALS Nevada New Hampshire VSP 001 Initials of preparer: © 2004 National Association of Insurance Commissioners 100 ASA New Hampshire Nevada Nebraska Montana Missouri Mississippi Minnesota Michigan Massachusetts Maryland Maine Louisiana Kentucky Kansas Iowa Indiana Illinois Idaho Hawaii Georgia Florida Dist. of Columbia Delaware Connecticut Colorado California Arkansas Arizona Alaska Alabama States Are you doing business in this 1 state? (Y/N) Total number of policies reviewed Viatical Settlement Broker's Name 2 for consideration Total number of policies 3 represented for viatication Total number of policies where 4 representation was refused Total number of policies sold to a 5 provider SECRETARY Aggregate net death benefit 6 viaticated Aggregate net amount paid to 7 viators Totals Canada U.S. Virgin Islands Puerto Rico Guam American Samoa Wyoming Wisconsin West Virginia Washington Virginia Vermont Utah Texas Tennessee South Dakota South Carolina Rhode Island Pennsylvania Oregon Oklahoma Ohio North Dakota North Carolina New York New Mexico New Jersey States All States and Territories Initials of preparer: Viatical Settlement Broker Report Are you doing business in this 1 state? (Y/N) Total number of policies reviewed 2 for consideration Total number of policies 3 represented for viatication Total number of policies where 4 representation was refused Total number of policies sold to a 5 provider Aggregate net death benefit 6 viaticated Aggregate net amount paid to 20 7 Calendar year viators Viatical Settlement Broker Reporting-All States and Territories Instructions NOTE: This form must be accompanied by "Viatical Settlement Provider/Broker Certification Form." 1. Indicate (Y or N) to all the states and territories where you are currently doing business. 2. Indicate the total number of policies you reviewed for consideration for that state or territory. 3. Indicate the total number of policies you represented for viatication in that state or territory. 4. Indicate the total number of policies you refused to represent for that state or territory. 5. Total number of policies sold to a provider. 6. List the total aggregate net amount of the policies you transacted for viatication in that state or territory. 7. Regarding transaction where you functioned as a broker, list the total aggregate net amount paid to viators in that state or territory. VSB 001 Instructions Initials of preparer: © 2004 National Association of Insurance Commissioners © 2004 National Association of Insurance Commissioners VSP 002 Viatical settlement provider settlement number 1 Contract date purchased 2 Viatical Settlement Provider's Name Total net death benefit ($) 3 Age of insured at time of 4 contract Life expectancy at time of 5 contract. Initials of preparer: Net amount paid to viator ($) 6 [State] Transactions Only Policy type: I or G 7 Viatical Settlement Provider Report Funding: F, P, I, T or RPT 8 Source of policy: 9 B, D, SM, P or o Commission amount ($) 10 20. Name of source of policy 11 Calendar year Viatical Settlement Provider Report [State] Insureds Only Instructions NOTE: This form must be accompanied by Viatical Settlement Provider/Broker Certification Form. 1. List the settlement number, case number or unique identifying number used to identify the specific viatical settlement transaction. 2. List the date the viatical settlement contract was purchased by the provider during the current calendar year, whether or not the insured is still alive at the end of the calendar year. 3. List the net amount (in dollars) being viaticated. 4. List the age (in years) of the person insured by the policy being viaticated, at the time of the viatical settlement contract. 5. List the life expectancy (in months) of the insured individual at the time of the viatical settlement contract. 6. List the net amount (in dollars) paid to the viator. 7. Identify whether the policy was an individual policy (I) or a group policy (G). 8. List the type of funding for the transaction: "F" for a licensed financial institution (policies collateralized), "P" for private (purchaser) funding, "I" for internal funding, "T" for trust, and "RPT" for related provider trust. 9. Indicate the purchase source of the policy. Use "B" for viatical settlement broker, "D" for direct from the viator, "I" for insurance agent/producer, "SM" for a secondary market or viatical settlement provider, "P" for private (purchaser) funding or "O" for other. 10. List the amount of commissions (in dollars) paid to viator source involved in the transaction whether that be a viatical settlement broker, an insurance producer or other licensed entity authorized to be viator source. 11. List the name of the source of the viatical settlement transaction. If it is a broker, producer or other licensee, name that person; if it is direct, from a relative, from the corporation of the insured or any other entity that could possibly reveal the insured, designate by writing "Direct," "Relative," "Corporation," or other nondesignating word. VSP 002 Instructions Initials of preparer: © 2004 National Association of Insurance Commissioners Viatical Settlement Broker Report Calendar year Viatical Settlement Broker's Name [State] Insureds Only 20 1 2 3 4 5 6 Viatical settlement provider's settlement number Contract date sold to viatical settlement provider Total net death benefit ($) Net amount paid to viator ($) Commission amount ($) Viatical settlement provider's name © 2004 National Association of Insurance Commissioners VSB 002 Initials of preparer: Viatical Settlement Broker Report-[State] Insureds Only Instructions NOTE: This form must be accompanied by "Viatical Settlement Provider/Broker Certification Form." 1. List the settlement number, case number, or unique identifying number used by the Viatical Settlement Provider to identify the specific viatical settlement transaction. 2. List the date sold of the viatical settlement contract to the Viatical Settlement Provider. 3. List the total net death benefit. 4. List the net amount (in dollars) paid to the viator. 5. List the amount of commissions (in dollars) paid to all viatical settlement brokers involved in the transaction. 6. List the name of the Viatical Settlement Provider involved in the viatical settlement transaction. VSB 002 Instructions Initials of preparer: © 2004 National Association of Insurance Commissioners Calendar year date of death (+/-) contract date and 20 10 expectancy at between life Number of months Initials of preparer: death contract and date of 9 between date of Number of months collected 8 Death benefit to maintain policy 7 Individual Mortality Report Total premiums paid [State] Insureds Only 6 Date of death viator 5 Net amount paid to Completed by Viatical Settlement Providers time of contract 4 Life expectancy at time of contract 3 Age of insured at Viatical Settlement Provider's Name 2 Contract date number 1 provider's settlement Viatical settlement VSP 003 © 2004 National Association of Insurance Commissioners Individual Mortality Report-[State] Insureds Only Instructions NOTE: This form must be accompanied by the Viatical Settlement Provider/Broker Certification Form. 1. List the settlement number, case number, or unique identifying number used to identify the specific viatical settlement transaction. 2. List the date of the viatical settlement contract. 3. List the age of the insured at the time of the contract. 4. List the life expectancy (in months) of the insured individual at the time of the viatical settlement contract. For first to die policies, use the shortest life expectancy of the two lives. For second to die policies, use the longest life expectancy of the two lives. 5. List the "Net" amount paid to the viator. 6. Indicate the insured's date of death. For first to die policies, use the date of the first insured's death. For second to die policies, use the date of the last insured's death. 7. List the total amount of premiums (in dollars) required to be paid to the insurer to maintain the policy from the date of viatication to the date of death. 8. List the total death benefit collected from the insurer. 9. List the number of months between the date of contract and the insured's date of death. 10. List the number of months between the life expectancy of the insured at the time of contract and the insured's date of death. This should be noted as a plus (+) figure if the insured died after the estimated life expectancy or a minus (-) if the insured died prior to the estimated life expectancy. VSP 003 Instructions Initials of preparer: © 2004 National Association of Insurance Commissioners Viatical Settlement Provider/Broker Certification Form This section should be completed by viatical settlement providers. Please check all forms submitted: Viatical Settlement Provider Reporting Form - All States and Territories (VSP 001) Viatical Settlement Provider Reporting Form - [State] Viators Only (VSP 002) Individual Mortality Report - [State] Insureds Only (VSP 003) I hereby certify that the information contained in the reports indicated above is true and accurate. I acknowledge that providing false and misleading information in the reports, or failing to divulge a fact material thereto, is sufficient grounds for administrative action by the commissioner and potentially, applicable criminal penalties Date: / / Signature of individual that prepared reports Print or type name Date: / / Signature of Authorized Representative Print or type name This section should be completed by viatical settlement brokers. Please check all forms submitted: Viatical Settlement Broker Reporting Form - [All States and Territories] (VSB 001) Viatical Settlement Provider Reporting Form - [State] Viators Only (VSB 002) I hereby certify that the information contained in the reports indicated above is true and accurate. I acknowledge that providing false and misleading information in the reports, or failing to divulge a fact material thereto, is sufficient grounds for administrative action by the commissioner and potentially, applicable criminal penalties Date: / / Signature of individual that prepared reports Print or type name Date: / / Signature of Authorized Representative Print or type name VSPB 001 © 2004 National Association of Insurance Commissioners