Ill. Admin. Code tit. 50, pt. 3701, exh. B - Viatical Settlement Broker Report and Instructions - All States and Territories (Form VSB-001)

__________________			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.

Notes

Ill. Admin. Code tit. 50, pt. 3701, exh. B

Recodified from 5701.EXHIBIT B at 42 Ill. Reg. 16457 Amended at 39 Ill. Reg. 16161, effective December 3, 2015