TITLE 50: INSURANCE
CHAPTER I: DEPARTMENT OF INSURANCE
SUBCHAPTER oo: VIATICAL SETTLEMENTS
PART 3701 VIATICAL SETTLEMENT PROVIDER AND BROKER REQUIREMENTS
SECTION 3701.EXHIBIT G VIATICAL SETTLEMENT BROKER CERTIFICATION (FORM VSB-004)



 

Section 3701.EXHIBIT G Viatical Settlement Broker Certification (Form VSB-004)

 

Viatical Settlement Broker Certification

 

 

This section should be completed by viatical settlement brokers.

 

Please check all forms submitted:

 

Viatical Settlement Broker Reporting Form All States and Territories

 

Viatical Settlement Broker Reporting Form Illinois Transactions Only

 

I hereby certify that the information contained in the reports indicated above is true and accurate. I acknowledge that providing false and misleading information in the reports, or failing to divulge a fact material thereto, is sufficient grounds for administrative action by the Director and, potentially, applicable criminal penalties.

 

 

 

Date:

/ /

Signature of individual that prepared reports

 

 

 

Print or type name

 

Date:

/ /

Signature of Authorized Representative

 

 

 

Print or type name

 

 

 

 

 

 

 

(Source: Added at 39 Ill. Reg. 4975, effective March 23, 2015)