Verification Of Coverage For Life Insurance Policies Page 2
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4IS 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 & 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
This column to be used by
Life Settlement Broker/Provider
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
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