VIATICAL SETTLEMENT DISCLOSURE PART B This part of the disclosure tells you exactly what you are buying. What you are purchasing You are investing $ and will receive, subject to certain possible deductions for premiums (see Disclosure Part A), on the death of the insured. The life expectancy of the insured in whose policy you are investing is estimated to be _______________. You are purchasing (check one): o % (percent) ownership of a life insurance policy with a $ _____________ death benefit o the entire ownership of a life insurance policy with a $ ___________ death benefit o ____________% (percent) of the death benefit of a life insurance policy with a $ ______________death benefit o the entire death benefit of a life insurance policy with a $ __________death benefit The insurance policy The life insurance policy was issued by: Company: Address: Telephone Number: The policy number is _______________. It was issued on ____________________. The policy is (check all that apply): o A term policy The term of the policy is: . o A group policy Name of the Group 08-114B (3/00) Page 1 American LegalNet, Inc. www.USCourtForms.com Address o A CONTESTABLE POLICY (See Disclosure Part A) The policy is contestable until (date) . Ownership After you make your purchase, you will be (check one): o an owner and beneficiary of a life insurance policy. Other owners of the policy will be: (attach list of names and addresses of other investors) o a beneficiary only of a life insurance policy. The owner(s) of the policy will be: (attach list of names, addresses, and telephone numbers) Other beneficiaries of the policy will be: (attach list of names and addresses of other investors) Premiums Premiums on the policy are (check one): o Paid up and no additional premium payments will ever be required. o Required to be paid periodically. Premiums are: $ annually Payments of $ 5 Monthly 08-114B (3/00) are due to be paid: 5 Quarterly 5 Semi-annually 5 Annually Page 2 American LegalNet, Inc. www.USCourtForms.com Term of premium payments (check one) o If premium payments are made as required the policy will be fully paid up on (date) ______________. o Premium payments must be made until the death of the insured. Funding of premium payments (check all that apply) o A portion of your investment has been set aside to pay premiums. This amount will fund the payment of premiums until (date) _________________. o These funds have been placed in an escrow account. Name of Escrow Agent Address Telephone Number Bank Name, address, and Account Number o You will be obligated to pay additional money to fund premium payments after (date)__________________. Payments of $ paid: 5 Monthly 5 Quarterly 5 Semi-annually will be due to be 5 Annually o Before these additional payments are due, you will be notified of when and to whom to make your premium payments. Use of your investment funds Of the amount you are investing: $ will be used to purchase the policy from the insured. $ will be set aside to pay premiums on the policy. $ will be used to pay a commission to the seller. $ ______will be used to pay administrative expenses and other transaction costs. 08-114B (3/00) Page 3 American LegalNet, Inc. www.USCourtForms.com