Individual Mortality Report

Calendar year

Viatical Settlement Provider's Name

Illinois Transactions Only

20____

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 of the viatical settlement contract.

3

List the age of the insured at the time of the contract.

4

List the life expectancy (in months) of the insured individual at the time of the viatical settlement contract.  For first to die policies, use the shortest life expectancy of the two lives. For second to die policies, use the longest life expectancy of the two lives.

5

List the "Net" amount paid to the viator.

6

Indicate the insured's date of death. For first to die policies, use the date of the first insured's death. For second to die policies, use the date of the last insured's death.

7

List the total amount of premiums (in dollars) required to be paid to the insurer to maintain the policy from the date of viatication to the date of death.

8

List the total death benefit collected from the insurer.

9

List the number of months between the date of contract and the insured's date of death.

10

List the number of months between the life expectancy of the insured at the time of contract and the insured's date of death. This should be noted as a plus (+) figure if the insured died after the estimated life expectancy or a minus (-) if the insured died prior to the estimated life expectancy.