Viatical Settlement Provider
Annual Statement

Due annually by March 1



Policies that have been settled within five years of such policy's date of issuance where insured is a resident of Kansas:
Total Number of Policies Aggregate Face Amount
of Policies
Aggregate life Settlement
Proceeds of Policies

Breakdown of information by policy issue year for any policy settled within five years of such policy's date of issuance where insured is a resident of Kansas:
Year Total Number of Policies
Per Year
Aggregate Face Amount of
Policies Per Year
Aggregate life Settlement
Proceeds of Policies
Per Year
Use one line per year. Click to add boxes for additional policy years.

ATTESTATION OF SUBMITTER:


   


 By checking this box, I attest and affirm that I am authorized to submit this annual statement on behalf of the Provider named herein, and that the information included is true, correct and complete to the best of my knowledge and belief. I understand that knowingly providing false or fraudulent information or knowingly making a material misrepresentation in connection with this annual statement or any information or reports required under the Viatical Settlements Act of 2002, K.S.A. 40-5001 et seq., may result, inter alia, in the revocation of the Provider’s license, or imposition of fines and penalties.

Date: 04/19/2024