Wash. Admin. Code § 284-97-920

Current through Register Vol. 24-24, December 15, 2024

Section 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.

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

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.

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.

	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?

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

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:

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

Page 4 of 4

Wash. Admin. Code § 284-97-920

Statutory Authority: RCW 48.02.060, 48.102.011, 48.102.046, 48.102.100, 48.102.170, 48.102.021, 48.102.041, and 48.102.080. 10-04-042 (Matter No. R 2009-14), § 284-97-920, filed 1/27/10, effective 2/27/10.