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