Viatical Settlement Broker Report

Calendar year

Viatical Settlement Broker's Name

Illinois Transactions Only

20____

1

2

3

4

5

6

Viatical settlement provider's settlement number

Contract date sold to viatical settlement provider

Total net death benefit ($)

Net amount paid to viator ($)

Commission amount

($)

Viatical Settlement  provider's  name

Name of Preparer:

Column

1

List the settlement number, case number or unique identifying number used by the Viatical Settlement Provider (VSP) to identify the specific viatical settlement transaction.

2

List the date the viatical settlement contract was sold to the VSP.

3

List the total net death benefit.

4

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

5

List the amount of commissions (in dollars) paid to all viatical settlement brokers involved in the transaction.

6

List the name of the VSP involved in the viatical settlement.