Code of Maine Rules
02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION
032 - OFFICE OF SECURITIES
Chapter 539 - OFFERS AND SALES OF VIATICAL OR LIFE SETTLEMENT CONTRACTS
Viatical Disclosure Document II

1. By law, you have the right to rescind the purchase of this investment by giving written notice of your intention to rescind. To be effective, your written notice of rescission must be postmarked no later than 30 days following the later of:

2. You are investing $ and will receive $ upon the death of the insured.

The life expectancy of the insured in whose policy you are investing is _______________.

3. You are purchasing (check one):

[] % (percent) ownership and death benefit of a life insurance policy with a $ _____________ death benefit.

[] the entire ownership and death benefit 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.

4. The life insurance policy was issued by:

Company:

Address:

Telephone Number:

5. The policy number is:

6. The policy was issued on (date):

7. 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).

8. After you make your purchase, you will be (check one):

[] 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)

[] 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)

9. Premiums on the policy are (check one):

[] Paid in full and no additional premium payments will ever be required. (If checked, go directly to item 12)

[] Required to be paid periodically.

Premiums are:

$ _________ annually

Payments of $ ___________ are due to be paid:

[] Monthly

[] Quarterly

[] Semi-annually

[] Annually

10. Term of premium payments (check one):

[] 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 insured.

11. 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 and Account Number:

[] You will be obligated to pay additional money 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.

[] Other (explain)______________________________________________________.

12. Of the amount you are investing:

$ ___________ will be used to purchase the policy from the owner.

$ ___________ 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.

The Maine Office of Securities is the agency of state government responsible for the licensing of brokerage firms, investment advisers and their employees, the registration of investment products, and enforcement of the State's securities laws. Anyone with questions or concerns about viaticals or other investments may call the Maine Office of Securities toll-free at 1-877-624-8551. We may be reached by mail at Maine Office of Securities, 121 State House Station, Augusta, ME 04333-0121.

This is (check one):

1. Issuer of the offering of viatical or life settlement contracts covered by this notice.

Note: 32 M.R.S.A. §16102(17)(D) defines the issuers of viatical or life settlement contracts as follows: the issuer of a fractional or pooled interest in a viatical or life settlement contract is the person who creates, for the purpose of sale, the fractional or pooled interest. The issuer of a viatical or life settlement contract that is not fractionalized or pooled is the person effecting the transaction with the investor in such a contract but does not include a broker-dealer or sales representative.

Name: ____________________________________________________________

Address: __________________________________________________________

__________________________________________________________

Telephone Number: _________________________________________________

Email Address: _____________________________________________________

2. Correspondent: to whom notices and communications regarding this application may be sent

Name: ____________________________________________________________

Firm: _____________________________________________________________

Address: __________________________________________________________

__________________________________________________________

Telephone Number: _________________________________________________

Email Address: _____________________________________________________

3. Form of Organization (check one)

___ Corporation ___ Unincorporated Association

___ Limited Liability Company ___ Other (specify) _________________________

___ Limited Partnership

Issuer's state or jurisdiction of incorporation or organization: ______________________

Date of incorporation or organization: __________________

4. This offering of viatical or life settlement contracts:

Description of contracts offered: _______________________________________

Number of contracts offered: __________________________________________

Price per contract: ___________________________________________________

Aggregate dollar amount of offering: ____________________________________

5. Provide the following information for each individual representing the issuer in making offers and sales of viatical settlements in Maine. Attach additional sheets, if necessary.

Name: ____________________________________________________________

Employer: _________________________________________________________

Title/position: ______________________________________________________

Address: ___________________________________________________________

___________________________________________________________

Telephone number: __________________________________________________

Will this individual be compensated, directly or indirectly, by the payment of commissions or other remuneration based on offers and sales of the viatical settlements the individual makes in Maine" Yes ______ No ______

If Yes, has this individual filed Uniform Form U-4 with the Office of Securities and paid the $50 fee" Yes ______ No ______

6. Provide the following information for each broker-dealer that will solicit purchasers in Maine. Attach additional sheets, if necessary.

Name: ___________________________________________________________

CRD#: ___________________________________________________________

Business Address: _________________________________________________

__________________________________________________

Telephone number: _________________________________________________

Together with this form, include the offering materials prepared in compliance with section 4(2) of Rule chapter 539 of the Office of Securities Rules, a nonrefundable $300 filing fee and a consent to service of process on Uniform Form U-2.

The issuer has read this notice and knows the contents to be true and has duly caused this notice to be signed on its behalf by the undersigned duly authorized person. The authorized person who signs the Notice of Exemption states that:

Signature: ___________________________________ Date: _______________________

___________________________________________

Name of Issuer (Printed or Typed)

___________________________________________

Name of Person Executing Notice (Printed or Typed)

___________________________________________

Title (Printed or Typed)