Ill. Admin. Code tit. 50, pt. 3701, exh. D
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: ______________________________
Instructions for Viatical Settlement Broker Report - Illinois Transactions Only
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. |
Ill. Admin. Code tit. 50, pt. 3701, exh. D