WAC 284-97-920. Verification of coverage for life insurance policies form

RCW 48.102.110 (2) provides that the request for verification of coverage must be made on a form approved by the commissioner. The following is the only verification of coverage form approved by the commissioner. verification of coverage for life insurance policies SUBMITTED TO : _____ NAIC# _____ Name of Insurance Company POLICY NUMBER : _____ SUBMITTED FROM : _____ Name of Life 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 LIFE SETTLEMENT PROVIDER/BROKER MUST PROVIDE. SUBMITTED TO : _____ NAIC# _____ Name of Insurance Company POLICY NUMBER : _____ SUBMITTED FROM : _____ Name of Life 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 LIFE SETTLEMENT PROVIDER/BROKER MUST PROVIDE. policy owner's and insured's information This column to be completed by Life Settlement Broker/Provider This column to be used by Insurance Company 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 information requested by this form by the insurance company to the life settlement broker/provider. Signature of owner Date signed This column to be completed by Life Settlement Broker/Provider This column to be used by Insurance Company 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 information requested by this form by the insurance company to the life settlement broker/provider. Signature of owner Date signed Page 1 of 4 is the policy in force? yes no if no, sign, and date on page 4 and return to the life settlement broker or provider that submitted the verification of coverage. is the policy in force? yes no if no, sign, and date on page 4 and return to the life settlement broker or provider that submitted the verification of coverage. policy type, riders and 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. * 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 Life Settlement Broker/Provider This column to be used by 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. * This column to be completed by Life Settlement Broker/Provider This column to be used by 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 policy values This column to be completed by Life Settlement Broker/Provider This column to be used by 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? This column to be completed by Life Settlement Broker/Provider This column to be used by 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 Life Settlement Broker/Provider This column to be used by 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 life settlement broker/provider The information submitted for verification by the life settlement broker/provider is correct and accurate to the best of my knowledge and has been obtained through the policy owner and/or insured. Signature Printed name This column to be completed by Life Settlement Broker/Provider This column to be used by 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 life settlement broker/provider The information submitted for verification by the life settlement broker/provider is correct and accurate to the best of my knowledge and has been obtained through the policy owner and/or insured. Signature Printed name Page 3 of 4 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: _____ 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/Life 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 Please provide the forms checked below: □ Absolute Assignment/Change of Ownership/Life 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