Verification Of Coverage For Life Insurance Policies Page 4
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4TO BE COMPLETED BY INSURANCE COMPANY
The information provided by verification by the insu rance company is co rrect 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/Viatical Assignment
o
Change of Beneficiary
o
Release of Irrevocable Beneficiary (if applicable)
o
Waiver of Premium Claim Form
o
Disability Waiver of Premium Approval Letter
o
Release of Assignment
o
Change of Death Benefit Option Form (if UL)
o
Allocation Change Form (if Variable)
o
Annual Report
o
Current In Force Illustration
o
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Parent category: Legal