D Viatical Settlement Broker Report and Instructions – Illinois Transactions Only (Form VSB-002)

Section 3701 .EXHIBIT D  Viatical Settlement Broker Report and Instructions – Illinois Transactions Only (Form VSB-002) 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.