Ill. Admin. Code tit. 50, § 3701.EXHIBIT A – Viatical Settlement Provider Report and Instructions – All States and Territories (Form VSP-001)

	Viatical Settlement Provider 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 where an offer was made	Total number of policies where an offer was not made	Total number of policies purchased	Aggregate total net death benefit	Aggregate amount paid to viators	Secondary market transactions
pur	sold

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

Name of Preparer:

Instructions for Viatical Settlement Provider 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 in the secondary market.

(Source: Amended at 39 Ill. Reg. 4975, effective March 23, 2015)