Viatical Settlement Broker Report

Calendar year

Viatical Settlement Broker'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

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.