APPENDIX A---Post-Sale Viatical Disclosure Document Read Immediately Upon Receipt You have invested in a viatical investment. A viatical investment is an agreement for the purchase of an interest in the death benefit of a life insurance policy. The individual whose life insurance policy is being sold is called the viator or insured. Right to Rescind or Cancel s and conditions of the viat ical investors right to rescind or cancel the 1. [Set forth the terms and conditions of the viat What you purchased 2. You have invested $ __________________ and will receive $ ______________ __ upon the death of the insured. The life expectancy of the insured in whose policy you are investing is _______________ The insured has the following medical condition: _______________________________ ________________________________________________________________________ 3. You have acquired: _______________ % (percent) ownership of a life insurance policy with a $ _______________ death benefit the entire ownership of a life insurance policy with a $ _____________________ death benefit _______________ % (percent) of the death benefit of a life insurance policy with a $ _______________________ death benefit the entire death benefit of a life insurance policy with a $ __________________ death benefit The insurance policy 4. The life insurance policy was issued by: Company: ______________________________________________________ Address: ______________________________________________________ ______________________________________________________ Telephone Number: ______________________________________________________ 5. The most recent A.M. Best rating for this insurance company is: ____________________ >>>> 26. The policy number is: ______________________________ 7. The policy was issued on (date): ______________________ 8. The policy is (check all that apply): A term policy The term of the policy is: _____________________________________________ A group policy Name of the Group: ________________________________________________ Address: ________________________________________________ ________________________________________________ Telephone Number: ________________________________________________ Contestable The policy is contestable until (date): ______________________________ _____ Ownership 9. As a result of your purchase, you are: an owner and beneficiary of a life insurance policy Other owners of the policy will be: (names and addresses of other investors) __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ a beneficiary only of a life insurance policy The owner(s) of the policy will be: (names, addresses, and telephone numbers) __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ Other beneficiaries of the policy will be: (names and addresses of other investors) __________________________________________________________________ Page 2 >>>> 3 __________________________________________________________________ __________________________________________________________________ Premiums 10. Premiums on the policy are: Paid up and no additional premium payments will ever be required. Required to be paid periodically. Premiums are: $ _____________________ annually Payments of $ _____________________ are due to be paid: Monthly Quarterly Semi-annually Annually 11. Term of premium payments If premium payments are made as required, the policy will be fully paid up on (date) __________________________ Premium payments must be made until the death of the viator. 12. Funding of premium payments (check all that apply): A portion of your investment has been set aside to pay premiums. This amount will fund the payment of premiums until (date) __________________________ These funds have been placed in an escrow account: Name of Escrow Agent: __________________________________________ Address __________________________________________ __________________________________________ Telephone Number __________________________________________ Bank Name __________________________________________ Page 3 >>>> 4 You will be obligated to pay addition maloney to fund premium payments after (date) _________________________. Payments of $ ________________ will be due to be paid: Monthly Quarterly Semi-annually Annually 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 13. Of the amount you are investing: $ ____________ will be used to purchase the policy. $ ____________ will be set aside to pay premiums on the policy. $ ____________ will be used to pay a commission to the person(s) who sold you the policy. $ ____________ will be used to pay administrative expenses and other transaction costs or payment to the viatical company. Name of viatical issuer: ________________________________________________ Address: ________________________________________________ Telephone: ________________________________________________ Page 4