19 Miss. Code. R. 2-15.13 - Appendix B- Verification of Coverage for Individual Policies

APPENDIX B

VERIFICATION OF COVERAGE FOR INDIVIDUAL POLICIES

Section One:

(To be completed by the Viatical Settlement Provider or Viatical Settlement Broker)

Insurance Company: _________________ Name of Policyowner ________________________

Policy number: _________________ Owner's Social Security Number: __________________

Name of Insured: ___________________ Policyowner's Address: ______________________

(street)

Insured's date of birth: _______________ ________________________________________

(City/State)

______________________________________________________________________________

Please provide the information requested in Section Two (below) with regard to the policy identified above and 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 Ownership/Viatical Assignment form

Change of Beneficiary

Release of Irrevocable Beneficiary (if applicable)

Waiver of Premium Claim Form

Disability Waiver of Premium Approval Letter

_______________________________ _____________________________________________

Date Signature of a representative of Viatical Settlement

Broker or Viatical Settlement Provider

______________________________________________________________________________

______________________________________________________________________________

Full name and address of Viatical Settlement Broker or Viatical Settlement Provider

______________________________________________________________________________

Section Two:

(To be completed by the life insurance company)

1) Face amount of policy: $ ____________________

2) Original date of issue: ________ / _________ / __________ Month/Date/Year)

3) Was face amount increased after original issue date? no yes

a) if yes, when: _______ / _________ / ________

4) Type of policy: _______________________ (Term/Whole Life/ Universal Life/Variable Life)

5) Is policy participating? no yes

a) If yes, what is current dividend election? _____________________________

6) Current net death benefit: __________________________ (Enter full amount payable, including any additional insurance, and/or dividends accumulated at interest, minus policy loans, outstanding interest on policy loans and/or accelerated death benefits paid)

7)

a)Current cash value: $ __________ (Enter full amount, including cash value of any additional insurance and/or dividends accumulated at interest, minus policy loans and outstanding interest on policy loans)

b) Current surrender value: $ ____________________

8) Terms of policy loans:

a) Amount of policy loans $ _________________

b) Amount of outstanding interest on policy loan: $ ___________________

c) Current interest rate: _____________________________

9) Has policy lapsed? no yes

a) If yes, when did policy lapse? _________ / _________ / ___________

If policy has lapsed, is coverage continued under non-forfeiture option? no yes

If yes, indicate which option, amount of coverage, duration, etc.: _________________

10) Is policy in force? no yes

a) If yes, has the policy been reinstated within the last two years? no yes If yes, date of reinstatement: ________ / ________ / __________

11) Amount of contract/scheduled premiums: $ ____________________________

12) Current premium mode: ______________________________ (Monthly, semi-annually, etc.)

a) When is next premium due? _____________ / ______ / _______ Month/Day/Year

13) Does the policy include a disability premium waiver provision/rider? no yes

a) If yes, are premiums currently being waived? no yes

b) If yes, since when _______ / ________ / _______

c) How often is continued eligibility reviewed? _____________

d) When is next review? _______ / ___________ / _________

14) Can payment of all or part of the death benefit be accelerated under this policy?

no yes

a) If yes, by what method is the benefit calculated, the lien method or the discount method? __________________

b) If lien method, what is the interest rate? __________

c) Can any remaining death benefit be assigned? no yes

15) Has a claim for accelerated death benefit been submitted? no yes

a) If yes, was payment made under this provision? no yes

Amount paid: ___________________ Date Paid: _________________________

16) Do current records show any assignments of record? no yes

17) Do current records show any outstanding liens or encumbrances of record? no yes

18) Please identify current primary beneficiaries: ________________________________

a) Are they named irrevocably, or is owner otherwise limited in designation of new beneficiaries? no yes

19) Have any riders been added to this policy after issue? no yes

If yes, please identify: ___________________________________________________

20) If an ownership or beneficiary change or assignment were to be made on this policy, to whom would the completed forms be sent?

Name: ______________________________________ Title: ____________________________

Company: ___________________________________ Department: ______________________

Address(no PO BOX, please) __________________________________________________

City: __________________________________ State: _________________ ZIP: _____________

Telephone No: _________________________________ Fax: __________________________

The answers provided reflect information contained in the company's records as of: __________

(date) Signature: __________________________________ Name (printed) _______________________

Title: _________________________________________________________________________

Company: _____________________________________________________________________

Direct Telephone No: __________________________ Direct Fax No: _____________________

Notes

19 Miss. Code. R. 2-15.13

Miss. Code Ann. § 83-7-219 (Rev. 2011)