Ill. Admin. Code tit. 50, pt. 3701, exh. E - Individual Mortality Report and Instructions - Illinois Transactions Only (Form VSP-003)

_______________________			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

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

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