Form Viad - Viatical Disclosure Document printable pdf download

Form Viad - Viatical Disclosure Document

This disclosure document is mandated by the Business Regulation and

Enforcement Division of the Office of the Mississippi Secretary of State.

VIATICAL DISCLOSURE DOCUMENT

(FORM VIAD PART II)

To be completed by the issuer or sales agent

You are purchasing a viatical settlement investment contract. A viatical

settlement investment contract is an agreement for the purchase of the death benefit of a

life insurance policy. The individual whose life insurance policy is being sold is called

the viator.

Right to Rescind

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:

The date on which you paid for your investment; or,

The date on which you received this disclosure document.

It must be mailed, postage prepaid, to:

Name: ___________________________________

Address: ____________________________________________________

What you are Purchasing

You are investing $________________ and will receive $__________________

upon the death of the viator.

The life expectancy of the viator in whose policy you are investing is _________

months.

You are purchasing (check one):

________% ownership of a life insurance policy with a $_______________

death benefit.

The entire ownership of a life insurance policy with a $_______________

death benefit.

Form Viad - Viatical Disclosure Document