Ill. Admin. Code tit. 50, § 3701.EXHIBIT D
| Viatical Settlement Broker Report | Calendar year | |
| Viatical Settlement Broker's Name | Illinois Transactions Only | 20____ |
| 1 | 2 | 3 | 4 | 5 | 6 |
| Viatical settlement provider's settlement number | Contract date sold to viatical settlement provider | Total net death benefit ($) | Net amount paid to viator ($) | Commission amount ($) | Viatical Settlement provider's name |
| Name of Preparer: |
Instructions for Viatical Settlement Broker Report –
Illinois Transactions Only
| Column | |
| 1 | List the settlement number, case number or unique identifying number used by the Viatical Settlement Provider (VSP) to identify the specific viatical settlement transaction. |
| 2 | List the date the viatical settlement contract was sold to the VSP. |
| 3 | List the total net death benefit. |
| 4 | List the net amount (in dollars) paid to the viator. |
| 5 | List the amount of commissions (in dollars) paid to all viatical settlement brokers involved in the transaction. |
| 6 | List the name of the VSP involved in the viatical settlement. |
(Source: Former EXHIBIT D renumbered to EXHIBIT F; new EXHIBIT D added at 39 Ill. Reg. 4975, effective March 23, 2015)