Viatical Disclosure Document Ii Form - Arkansas Securities Department Page 2
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4The insurance policy
The life insurance policy was issued by:
Company:
Address:
Telephone Number:
The policy number is:
The policy was issued on (date):
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
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: (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
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