Exhibit D - Viatical Settlement Broker Report and Instructions - Illinois Transactions Only (Form VSB-002)

Current through Register Vol. 46, No. 15, April 8, 2022

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.

Notes

Recodified from 5701.EXHIBIT D at 42 Ill. Reg. 16457 Former EXHIBIT D renumbered to EXHIBIT F; new EXHIBIT D added at 39 Ill. Reg. 4975, effective March 23, 2015

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