Kansas Department of Insurance

Viatical Settlement Provider Annual Statement due March 1



For each policy your company has settled in the past five years in which the insured is a resident of Kansas, provide the following information. Use one line per policy. See footnotes at bottom of page for additional instructions. Please refer to K.A.R. 40-2-31 for Minimum Requirements for Viaticating a Policy.
Year
Settled
Face
Amount
Settlement
Proceeds
Age of
Policy-
holder
Date of
Issuance1
Life
expectancy
of policy-
holder2
Method
of Life
Expectancy
Determination
Cash
surrender
value3
Accelerated
Death
Benefit
(ADB)4
Was
ADB
Paid?5
Outstanding
loans6
If viator now
deceased,
provide date
of death

Click to add lines/boxes for additional policies.

ATTESTATION OF SUBMITTER:




        

 By checking this box, I attest and affirm that I am authorized to submit this information 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 form 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: 08/06/2025



1This should indicate how long the policy had been in force.

2The answer should be given in months. The life expectancy of the policyholder means the average number of months that the insured was expected to live at the time of the settlement as determined by the viatical settlement provider, considering medical records and appropriate experiential data.

3As of the date of settlement, less any outstanding loan(s) against the policy.

4Refer to K.A.R. 40-2-20. Indicate amount of Accelerated Death Benefit available to policyholder at time of settlement, less any outstanding loan(s) against the policy. If none, state “None.”

5See footnote 4.

6Indicate amount of outstanding loans against the policy which was deducted from the settlement amount.