Ill. Admin. Code tit. 50, pt. 3701, exh. B
__________________ | Viatical Settlement Broker 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 represented for viatication | Total number of policies where representation was refused | Total number of policies sold to provider | Aggregate net death benefit viaticated | Aggregate net amount paid to viators | Number of policies purchased/sold on the secondary market |
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 | ||||||||
Instructions for Viatical Settlement Broker 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 on the secondary market. |
Ill. Admin. Code tit. 50, pt. 3701, exh. B