TITLE 50: INSURANCE
CHAPTER I: DEPARTMENT OF INSURANCE
SUBCHAPTER oo: VIATICAL SETTLEMENTS
PART 3701 VIATICAL SETTLEMENT PROVIDER AND BROKER REQUIREMENTS
SECTION 3701.EXHIBIT B VIATICAL SETTLEMENT BROKER REPORT AND INSTRUCTIONS - ALL STATES AND TERRITORIES (FORM VSB-001)



Section 3701.EXHIBIT B Viatical Settlement Broker Report and Instructions − All States and Territories (Form VSB-001)

 

 

Viatical Settlement Broker Report

Calendar year

Viatical Settlement Broker's Name

All States and Territories

20____

 

 

1

2

3

4

5

6

7

8

States

Are you doing business in this state? (Y/N)

Total number of policies reviewed for consideration

Total number of policies represented for viatication

Total number of policies where representation was refused

Total number of policies sold to provider

Aggregate net death benefit viaticated

Aggregate net amount paid to viators

Number of policies purchased/sold on the secondary market

Alabama

 

 

 

 

 

 

 

 

Alaska

 

 

 

 

 

 

 

 

Arizona

 

 

 

 

 

 

 

 

Arkansas

 

 

 

 

 

 

 

 

California

 

 

 

 

 

 

 

 

Colorado

 

 

 

 

 

 

 

 

Connecticut

 

 

 

 

 

 

 

 

Delaware

 

 

 

 

 

 

 

 

Dist. of Columbia

 

 

 

 

 

 

 

 

Florida

 

 

 

 

 

 

 

 

Georgia

 

 

 

 

 

 

 

 

Hawaii

 

 

 

 

 

 

 

 

Idaho

 

 

 

 

 

 

 

 

Illinois

 

 

 

 

 

 

 

 

Indiana

 

 

 

 

 

 

 

 

Iowa

 

 

 

 

 

 

 

 

Kansas

 

 

 

 

 

 

 

 

Kentucky

 

 

 

 

 

 

 

 

Louisiana

 

 

 

 

 

 

 

 

Maine

 

 

 

 

 

 

 

 

Maryland

 

 

 

 

 

 

 

 

Massachusetts

 

 

 

 

 

 

 

 

Michigan

 

 

 

 

 

 

 

 

Minnesota

 

 

 

 

 

 

 

 

Mississippi

 

 

 

 

 

 

 

 

Missouri

 

 

 

 

 

 

 

 

Montana

 

 

 

 

 

 

 

 

Nebraska

 

 

 

 

 

 

 

 

Nevada

 

 

 

 

 

 

 

 

New Hampshire

 

 

 

 

 

 

 

 

New Jersey

 

 

 

 

 

 

 

 

New Mexico

 

 

 

 

 

 

 

 

New York

 

 

 

 

 

 

 

 

North Carolina

 

 

 

 

 

 

 

 

North Dakota

 

 

 

 

 

 

 

 

Ohio

 

 

 

 

 

 

 

 

Oklahoma

 

 

 

 

 

 

 

 

Oregon

 

 

 

 

 

 

 

 

Pennsylvania

 

 

 

 

 

 

 

 

Rhode Island

 

 

 

 

 

 

 

 

South Carolina

 

 

 

 

 

 

 

 

South Dakota

 

 

 

 

 

 

 

 

Tennessee

 

 

 

 

 

 

 

 

Texas

 

 

 

 

 

 

 

 

Utah

 

 

 

 

 

 

 

 

Vermont

 

 

 

 

 

 

 

 

Virginia

 

 

 

 

 

 

 

 

Washington

 

 

 

 

 

 

 

 

West Virginia

 

 

 

 

 

 

 

 

Wisconsin

 

 

 

 

 

 

 

 

Wyoming

 

 

 

 

 

 

 

 

American Samoa

 

 

 

 

 

 

 

 

Guam

 

 

 

 

 

 

 

 

Puerto Rico

 

 

 

 

 

 

 

 

U.S Virgin Islands

 

 

 

 

 

 

 

 

Canada

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TOTALS

 

 

 

 

 

 

 

 

 

Instructions for Viatical Settlement Broker Report

All States and Territories

 

COLUMN

 

1

By a "Y" for yes or an "N" for no, indicate if you have or have not done business in the state during the calendar year being reported.

2

For each state or territory in which you have done business during the calendar year being reported, indicate the total number of policies reviewed for consideration.

3

For each state or territory in which you have done business during the calendar year being reported, indicate the total number of policies for which an offer was made.

4

For each state or territory in which you have done business during the calendar year being reported, indicate the total number of policies for which an offer was refused.

5

For each state or territory in which you have done business during the calendar year being reported, indicate the total number of policies purchased.

6

For each state or territory in which you have done business during the calendar year being reported, list the total aggregate net death benefit of the policies viaticated.

7

For each state or territory in which you have done business during the calendar year being reported, list the total aggregate amount paid to viators.

8

For each state or territory in which you have done business during the calendar year being reported, list the total number of policies purchased and/or sold on the secondary market.

 

(Source: Amended at 39 Ill. Reg. 16161, effective December 3, 2015)