Ill. Admin. Code tit. 50, pt. 3701, exh. H - Verification of Coverage for Life Insurance Policies

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 Viatical 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 of information requested by this form by the insurance company to the viatical settlement broker/provider.

______________________________________________________________________

Signature of policy owner Date signed

Form VOC

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.

* ______ 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 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.	*

POLICY VALUES

This column to be completed by Viatical 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 Viatical 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 VIATICAL SETTLEMENT BROKER/PROVIDER

The information submitted for verification by the viatical 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 Named

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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

Notes

Ill. Admin. Code tit. 50, pt. 3701, exh. H

Recodified from 5701.EXHIBIT H at 42 Ill. Reg. 16457 Added at 39 Ill. Reg. 16161, effective December 3, 2015