Verification Of Coverage For Life Insurance Policies
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4VERIFICATION 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 CHECK MARK 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
This column to be used by
Life Settlement Broker/Provider
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 life settlement broker/provider.
__________________________________________
________________________
Signature of policy owner
Date signed
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