Ill. Admin. Code tit. 50, § 3701.EXHIBIT B
| 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 |
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. |
(Source: Amended at 39 Ill. Reg. 16161, effective December 3, 2015)