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1. Name of insurance company
2. Name of policy owner
3. Name of insured
4. Face value of policy $ (no commas)
5. Date of sale transaction (mm/dd/yyyy)
6. Type of insurance policy - whole life or term?
7. Cash surrender value at sale date $ (no commas)
8. Cumulative premiums paid since inception $ (no commas)
9. Cumulative cost of insurance charges since inception $ (no commas)
10. Cumulative withdrawals, distributions, and loans since inception (enter 0.00 if none) $ (no commas)
11. Sales proceeds from life insurance settlement $ (no commas)
12. Unearned premium at sale date if term type policy (enter 0.00 if none) $ (no commas)
13. Your marginal ordinary income tax rate %
14. Your long-term capital gains tax rate %
15. Is this a viatical settlement or insurance
payment to a chronicallyThe term ''chronically ill individual'' is defined as:

An individual whose condition has been certified by a licensed health care practitioner within the last twelve (12) months.

AND who:

Is unable to perform (without substantial assistance from another individual) at least 2 activities of daily living (see list below) for a period of at least 90 days due to a loss of functional capacity, or

Has a level of disability similar to the condition described above, or

Requires substantial supervision to protect such individual from threats to health and safety due to severe cognitive impairment.

  • Activities of daily living:
  • Eating
  • Toileting
  • Transferring
  • Bathing
  • Dressing
  • Continence
  • or terminallyA terminally ill person is defined as someone who has been certified by a medical doctor as having an illness or physical condition which can be reasonably expected to result in death within 24 months from the date of certification. ill individual?