Ill. Admin. Code tit. 50, pt. 920, ILLUSTRATION A
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: |
* 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 | 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: |
* 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 INFORMATIONPLEASE 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: __________________________________________________
Ill. Admin. Code tit. 50, pt. 920, ILLUSTRATION A