Viatical Settlement Provider Report

Calendar year

Viatical Settlement Provider's Name

Illinois Transactions Only

20____

1

2

3

4

5

6

7

8

9

10

11

Viatical settlement provider settlement number

Contract date purchased

Total net death benefit ($)

Age of insured at time of contract

Life expectancy at time of contract

Net amount paid to viator ($)

Policy type:

I or G

Funding:

F, P, I, T or RPT

Source of policy:

B, D, SM,

P or O

Commission amount ($)

Name of source of policy

Name of Preparer:

Column

1

List the settlement number, case number or unique identifying number used to identify the specific viatical settlement transaction.

2

List the date the viatical settlement contract was purchased by the provider during the current calendar year, whether or not the insured is still alive at the end of the calendar year.

3

List the net amount (in dollars) being viaticated.

4

List the age (in years) of the person insured by the policy being viaticated, at the time of the viatical settlement contract.

5

List the life expectancy (in months) of the insured individual at the time of the viatical settlement contract.

6

List the net amount (in dollars) paid to the viator.

7

Identify whether the policy was an individual policy (I) or a group policy (G).

8

List the type of funding for the transaction: "F" for a licensed financial institution (policies collateralized), "P" for private (purchaser) funding, "I" for internal funding, "T" for trust, and "RPT" for related provider trust.

9

Indicate the purchase source of the policy. Use "B" for viatical settlement broker, "D" for direct from the viator, "I" for insurance agent/producer, "SM" for a secondary market or viatical settlement provider, "P" for private (purchaser) funding or "O" for other.

10

List the amount of commissions (in dollars) paid to viator source involved in the transaction whether that be a viatical settlement broker, an insurance producer or other licensed entity authorized to be viator source.

11

List the name of the source of the viatical settlement transaction. If it is a broker, producer or other licensee, name that person; if it is direct, from a relative, from the corporation of the insured or any other entity that could possibly reveal the insured, designate by writing "Direct", "Relative", "Corporation", or other nondesignating word.