A Viatical Settlement Provider Report and Instructions – All States and Territories (Form VSP-001)

Section 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.