Section 920.ILLUSTRATION A Illinois Department of Insurance Lost Policy Finder Service Form

320 W. Washington Street

Springfield IL 62767

Main Phone 866-445-5364

Local 217-557-6955

TDD 217-524-4872

insurance.illinois.gov

Illinois Department of Insurance

Lost Policy Finder Service

The Illinois Department of Insurance can forward a consumer's request to locate and identify individual life insurance policies or annuity contracts of a deceased family member.

WHO IS ELIGIBLE FOR THE LOST POLICY FINDER SERVICE:		HOW TO SUBMIT A REQUEST: Please complete all information indicated on this form, and return your request in an envelope marked "CONFIDENTIAL" along with a COPY of a proof of death, such as the deceased's death certificate, to:
●	An executor or legal representative of a deceased individual who may have lived in Illinois when an individual life insurance policy or individual annuity was purchased, or
●	Individuals who have reason to believe they are beneficiaries.	IL DOI-Lost Policy Finder Service 320 W. Washington St. Springfield IL 62767
		*You should keep the original death certificate. Insurers will require an original death certificate in the event that you are contacted to submit a claim.*

*******IMPORTANT: Life insurers will respond directly to you ONLY IF they have reason to believe the deceased has individual policies or contracts with them

AND you are authorized to receive this information.*******

CONFIDENTIAL PERSONAL INFORMATION PLEASE WRITE CLEARLY IN BLACK OR BLUE INK

Requestor's Name (Person completing the form) (Mr. Ms. Mrs. Dr., etc.)		Date of Request
Street Address	City	State	Zip Code
Phone Number(s)	E-mail Address

Deceased Person's Information

Name of Deceased Policyholder or Annuitant (Please include all previous legal names (i.e., maiden name))*				Deceased's Social Security Number
Policyholder/Annuitant's Most Recent Street Address		City		State	Zip Code
Policyholder/Annuitant's Previous Street Addresses*		City		State	Zip Code
Date of Birth	Date of Death		State of Purchase

*Please attach separate page if more space is needed

Relationship of Requestor to the Deceased Person (check all that apply)

Spouse

Child (18 or older)

Executor or Legal Representative

Attorney

Other (Please specify below)

□

Upon receipt of the fully completed request form and proof of death, such as a death certificate copy, the Department of Insurance will:

● Forward the form and attachments, along with the proof of death, to all Illinois-licensed life insurers.

● Ask that the insurers search their records to determine whether they have any individual life insurance policies or annuity contracts in the name of the deceased.

● Ask that the insurers respond directly to the requestor only if they have any individual life insurance policies or annuity contracts naming the deceased, and if the requestor is authorized to receive this information.

REQUESTOR'S CERTIFICATION

I certify that I have made a diligent search of the deceased person's records and property, including bank statements and safety deposit boxes, and have asked family members to identify all individual life policies or individual annuity contracts that I have reason to believe covered the life of the deceased person named above. I understand that life insurers will respond directly to me only if they have reason to believe the deceased has any individual policies with them and I am authorized to receive this information.

I understand that the Department of Insurance's only role with this request is to forward to all Illinois licensed life insurers this completed form and the proof of death. I understand that the Department may reject this request if the Department, in its sole discretion, deems it to be incomplete, frivolous, or unduly burdensome. I understand that an insurer may require additional information from me, including the original death certificate and documentation of my legal authority to request or obtain information about the deceased.

For privacy and protection of confidential personally identifiable information, I understand all original documents I submit to the Illinois Department of Insurance will not be returned. I further understand all original documents I submit with this request will be destroyed pursuant to Department retention schedules.

I certify that the information I have provided is complete and accurate.

Requestor's Signature: ______________________________________________________