G Viatical Settlement Broker Certification (Form VSB-004)

Section 3701.EXHIBIT G   Viatical Settlement Broker Certification (Form VSB-004) Viatical Settlement Broker Certification This section should be completed by viatical settlement brokers. Please check all forms submitted: ¨ Viatical Settlement Broker Reporting Form – All States and Territories ¨ Viatical Settlement Broker Reporting Form – Illinois Transactions Only I hereby certify that the information contained in the reports indicated above is true and accurate.  I acknowledge that providing false and misleading information in the reports, or failing to divulge a fact material thereto, is sufficient grounds for administrative action by the Director and, potentially, applicable criminal penalties. Date: /       / Signature of individual that prepared reports Print or type name Date: /       / Signature of Authorized Representative Print or type name