Ill. Admin. Code tit. 50, pt. 3701, exh. E
_______________________ | Individual Mortality Report | Calendar year | |||||||
Viatical Settlement Provider's Name | Illinois Transactions Only | 20____ | |||||||
1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 |
Viatical settlement provider's settlement number | Contract date | Age of insured at time of contract | Life expectancy at time of contract | Net amount paid to viator | Date of death | Total premiums paid to maintain policy | Death benefit collected | Number of months between date of contract and date of death | Number of months between life expectancy at contract date and date of death (+ / -) |
Name of Preparer: ________________________________
Instructions for Individual Mortality Report - Illinois Transactions Only
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. |
Ill. Admin. Code tit. 50, pt. 3701, exh. E