Policy Review

In-Force Policy Review Authorization

Complete this form to authorize Dogpatch Insurance Solutions to request in-force illustrations and policy information from your current insurance carrier so we can review your existing coverage. Fields marked * are required.

Policy & Owner Information

Tell us about the policy you'd like reviewed.

Current insurance company*

Insured*

Date of birth

Policy owner*

Social Security # or TIN

Address

Policy number(s)*

Separate multiple policy numbers with commas.

Authorization to Access

Who you are granting permission to review your policy.

I authorize the following advisor to access my policy information*

In-Force Illustration Request

Choose the hypothetical interest rates and illustration types to request.

Interest rate assumptions

Illustrate at the current and guaranteed rates

Also illustrate at a hypothetical rate of return of 0% and the following selected rates:

Other rate (%)

Type of illustration(s)

Full pay — continue paying the scheduled premium in all yearsLimited pay — stop scheduled premium payments once policy values are adequate to endow the policySolve for the level premium required to endow the policyProvide current account value, surrender value, and beneficiary designations

Other request

Electronic Signature & Acknowledgement

Typing your name below serves as your electronic signature.

Policyowner signature (type your full name)*

Date*

Capacity (if signing on behalf of the owner)

I acknowledge that the name I typed above is my electronic signature and authorizes Dogpatch Insurance Solutions to request in-force illustrations and policy information from the insurance carrier named above. I understand this is not tax or legal advice.

Your submission is emailed securely to Dogpatch Insurance Solutions.