Viatical Settlement Provider Data Inquiry



For each policy your company has settled from January 1, 2018 to date, 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.
Year
Settled		 Face
Amount		 Settlement
Proceeds		 Age of
Policyholder		 Date of
Issuance1		 Life
expectancy of
policyholder2		 Cash
surrender
value3		 Accelerated Death
Benefit (ADB)4		 Was ADB
Paid?5		 Outstanding
loans6

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: 04/29/2024


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. If life expectancy was over 24 months state “24+”. If no determination of life expectancy was made, state “N/A.” If no life expectancy determination was made but policyholder has since died, insert date of policyholder’s death.

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.