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Viatical/Life Settlement Provider Annual Statement

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Viatical/Life Settlement Provider Annual Statement Judith L. French, Director VIATICAL/LIFE SETTLEMENT PROVIDER ANNUAL STATEMENT to the Ohio Department of Insurance pursuant to section 3916.12(A) of the Ohio Revised Code For (Name of Viatical/Life Settlement Provider) Viatical/Life Settlement Provider Ohio License Number Ohio Department of Insurance Office of Risk Assessment For The Year Ended December 31, Mail Completed Annual Statement to: Ohio Department of Insurance Risk Assessment Attn: Viatical/Life Settlements 50 West Town Street, Suite 300 Columbus, Ohio 43215 INS7248 (Rev. 02/2021) Page 1 of 4 Judith L. French, Director Name of Authorized Representative: Title: Name of Authorized Representative: Title: State of Domicile : Street Address of Licensee: Year Licensee Organized: City: State: Zip Code: We, the undersigned, do hereby certify that we are the duly elected authorized representatives of , (the “Licensee”), a(n) Name of Licensee form of organization and that we are authorized to execute and deliver this statement on behalf of the Licensee. We further certify that the information provided in this Annual Statement required by Ohio Revised Code (“R.C.”) section 3916.12(A) and incorporated by reference herein is complete and accurate. Authorized Representative Authorized Representative (Signature) (Signature) (Printed Name) (Printed Name) (Title) (Title) Subscribed and sworn to before me this day of , 20 Notary Public My Commission Expires Instructions: Pursuant to Ohio Revised Code section 3916.12(A), this Viatical/Life Settlement Provider Annual Statement must be completed and submitted to the Ohio Department of Insurance by March 1 of each year for activity during the immediately preceding calendar year (the “Statement Year”) and, where indicated, activity for the five years immediately preceding the Statement Year. This Annual Statement must be signed by two authorized representatives of the Licensee and the signatures must be notarized. The Annual Statement is considered incomplete if it is not properly authorized and notarized. INS7248 (Rev. 02/2021) Page 2 of 4 Ohio Department of Insurance Viatical/Life Settlement Annual Statement for Providers SCHEDULE A – AGED SCHEDULE OF UNSETTLED VIATICAL SETTLEMENT CONTRACTS Revised Code section 3916.12(A)(1) Aggregate total of the value of unsettled viatical settlement contracts that have been signed by (an Ohio Resident) the viator as of January 1, 2020, but have not been settled as of December 31, 2020. NUMBER OF AGGREGATE TOTAL VALUE OF UNSETTLED SIGNED UNSETTLED CONTRACTS CONTRACTS SCHEDULE B – SCHEDULE OF SETTLED VIATICAL CONTRACTS Revised Code section 3916.12(A)(2) (From an Ohio Resident) Number of policies purchased, total amount of settlement paid for policies purchased, total face value of policies purchased beginning with the statement year and most recent five years. Total Number of Policies Total Amount of Settlement Total Face Value of Policies Year Purchased Paid for Policies Purchased Purchased 2020 2019 2018 2017 2016 2015 SCHEDULE C – SETTLEMENTS PAID ALLOCATED BY STATE OR TERRITORY Revised Code section 3916.12(A)(3) Number of settlements paid in the preceding calendar year, allocated by state or territory. Revised Code section 3916.12(A)(4) Any other information required by superintendent – Statement includes total amount of settlements paid for policies purchased and total face value of policies for which a settlement was paid for each state or territory. INS7248 (Rev. 02/2021) Page 3 of 4 Ohio Department of Insurance Viatical/Life Settlement Annual Statement for Providers TOTAL AMOUNT OF TOTAL FACE VALUE OF NUMBER OF STATE OR SETTLEMENT PAID FOR POLICIES FOR WHICH A SETTLEMENTS PAID TERRITORY POLICIES PURCHASED SETTLEMENT WAS PAID PREVIOUS YEAR (TOTAL DOLLAR AMOUNT) (TOTAL DOLLAR AMOUNT) Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin US Territory (All) INS7248 (Rev. 02/2021) Page 4 of 4 .
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