Policy Performance Review

Policy Performance Review
Agent Info
Agent Name

First NameLast Name
VERIFICATION OF COVERAGE
Today’s date

MonthDayYear
Date
Policy number
Policy date

MonthDayYear
Date
Issue date

MonthDayYear
Date
Name of carrier
State of issue
Policy Owner and Insured Information
Name of First Insured

First NameLast Name
Date of birth

MonthDayYear
Date
Name of Second Insured

First NameLast Name
Date of birth

MonthDayYear
Date
Name of Owners

First NameLast Name
Name of beneficiary(ies)
Are any beneficiaries irrevocable?

YesNo
Name of Owners at Issue

First NameLast Name
Policy Values
Effective Date

MonthDayYear
Date
Face amount
Net death benefit
Death benefit rider amount
Product name
Maturity date

MonthDayYear
Date
What is the policy type?

TermWhole LifeUniversal LifeVariable
Is this a group policy? If yes, certificate number.

YesNo
If yes, certificate number
Group number
What is the death benefit option?

LevelIncreasingROP
Account value
Cash surrender value
Surrender charges
Monthly cost of insurance (COI)
Date of last cost of insurance (COI) deduction

MonthDayYear
Date
Premium loads (%)
Monthly administration fee
Has the carrier announced, or is the carrier planning, any cost of insurance COI or rate increase for this product (other than standard anniversary date increases)?

YesNo
If yes, please provide details
Are there any loans on the policy?

YesNo
Current outstanding loan payoff amount (if any)
Current loan interest rate
Is the loan interest charged in advance or arrears?
Current loan crediting rate
No Is the APL provision effective?

YesNo
Was this policy issued by a conversion?

YesNo
If yes, provide the date of the original policy

MonthDayYear
Date
If yes, provide the name of owner(s) of the original policy at issue
Premium Information
Date of last premium payment

MonthDayYear
Date
Amount paid
Total premium paid to date
Date of next premium payment

MonthDayYear
Date
Amount due
Mode of payment
If the policy is a term or whole life policy, date to which policy is paid

MonthDayYear
Date
If the policy was recently converted, please provide the conversion credit
Are the premiums paid by an automatic bank draft?

YesNo
If the policy is a term policy, is monthly payment an option if there is no automatic bank draft?

YesNo
If no, what is the premium amount due to pay the policy to the next quarterly due date?

MonthDayYear
Date
Note that the intention is to keep the policy’s premium payments payable on the quarterly due dates that coincide with the policy’s anniversary.
Lapse date (if no additional premiums are paid)

MonthDayYear
Date
Will changing the mode to quarterly reset the payment date?

YesNo
Is the policy in grace or is it lapse pending? If yes, please provide the amount due and date below.

YesNo
Amount Due
Lapse date (if no additional premiums are paid)

MonthDayYear
Date
Policy Information
Is the policy past the contestability and suicide period?

YesNo
Has the policy ever lapsed or been re-instated?

YesNo
If yes, provide date

MonthDayYear
Date
Does the policy have any liens or collateral assignments? If yes, provide the name of the assignee:
Was the policy issued with a table rating or flat extra? If yes, provide the table rating or the amount of flat extra:
What was the rating class at issue?
What was the smoker status at issue?
Is this policy a survivorship?

YesNo
If yes, is either insured deceased?

YesNo
If yes, provide name of the deceased insured:
Is the original certified death certificate on file?

YesNo
If the policy is a whole life policy, are the dividends payable? If yes, provide the current dividend option:
If yes, provide the final date to convert and the rating class

AnnualIf the policy is variable, how are the current funds allocated?
If the policy is a term policy, is it convertible?

YesNo
If yes, provide the final date to convert and the rating class

MonthDayYear
Date
If the policy is whole life, provide the premium amounts for each of the following modes:
Annual
Semi-annual
Quarterly
Monthly
If the policy is variable, how are the current funds allocated?
If the policy is variable, how are the future contributions allocated?
Carrier Contact Information
Name of carrier contact:
ID Number
Phone
Type Signature:
Date

MonthDayYear
Date
Customer Support P.O. Box 1409 Wake Forest NC 27587 919-488-3686
Should be Empty:

Policy Performance Review

Agent Info

VERIFICATION OF COVERAGE

Policy Owner and Insured Information

Policy Values

Premium Information

Policy Information

Carrier Contact Information