Ill. Admin. Code tit. 50, pt. 3701, exh. A
______________________ | Viatical Settlement Provider Report | Calendar year | |||||||
Viatical Settlement Provider'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 where an offer was made | Total number of policies where an offer was not made | Total number of policies purchased | Aggregate total net death benefit | Aggregate amount paid to viators | Secondary market transactions | |
pur | sold | ||||||||
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 | |||||||||
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Name of Preparer: ________________________________
Instructions for Viatical Settlement Provider 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 in the secondary market. |
Ill. Admin. Code tit. 50, pt. 3701, exh. A