Viatical Disclosure Document Part B Right to Rescind By law, you have the right to rescind (cancel) the purchase of this investment by giving written notice of your intention to rescind. To be effective, your written notice of rescission must be either postmarked or delivered to the entity indicated below no later than 10 days following the date on which you sign a viatical settlement purchase agreement. It must be mailed, postage prepaid, or delivered to: Name: Address: What you are purchasing 1. You are investing $ and will receive $ upon the death of the insured, subject to certain possible deductions for premiums (see Disclosure Part A). The life expectancy of the insured in whose policy you are investing is . 2. You are purchasing (check one): % (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 1 KY Form 10:410B February 2001 edition American LegalNet, Inc. www.USCourtForms.com the entire death benefit of a life insurance policy with a $ death benefit The insurance policy 3. The life insurance policy was issued by: Company: Address: Telephone Number: 4. The policy was issued on (date): 5. 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) . Non-Contestable (subject to state law). Ownership 6. After you make your purchase, you will be (check one): 2 KY Form 10:410B February 2001 edition American LegalNet, Inc. www.USCourtForms.com an owner and beneficiary of a life insurance policy. a beneficiary only of a life insurance policy. Other, as follows: Premiums 7. Premiums on the policy are (check one): Paid up and no additional premium payments will ever be required. Required to be paid periodically. Premiums are: annually $ Payments of $ Monthly are due to be paid: Quarterly Annually Semi-annually Other, as follows: 8. Term of premium payments (check one) If premium payments are made as required, then the policy will be fully paid up on (date) , except in the event the policy premium changes. Premium payments must be made until the death of the insured. 9. 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) unless the amount of premium required under the policy changes. These funds have been placed in an escrow account. 3 KY Form 10:410B February 2001 edition American LegalNet, Inc. www.USCourtForms.com Name of Escrow Agent Address Telephone Number Bank Name and Account Number You will be obligated to pay additional money to fund premium payments after (date) . Payments of $ Monthly Quarterly will be due to be paid: Semi-annually Annually Before these additional payments are due, you will be notified of when and to whom to make your premium payments. Other, as follows: Use of your investment funds 10. 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 person who sold you the policy. $ will be used to pay administrative expenses and other transaction costs. 4 KY Form 10:410B February 2001 edition American LegalNet, Inc. www.USCourtForms.com