Exhibit E - Individual Mortality Report and Instructions - Illinois Transactions Only (Form VSP-003)

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

_______________________

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.

Notes

Recodified from 5701.EXHIBIT E at 42 Ill. Reg. 16457 Former EXHIBIT C renumbered to EXHIBIT E and amended at 39 Ill. Reg. 4975, effective March 23, 2015

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