The following information are needed for us to grant your request in selling your structured settlement or annuity payments. 

You may submit this form to us by printing it out and mailing it to us or you can call and tell us the information and we will contact you within 48 to 72 hours with a "lump sum" quote based on the information you provide us below.

STRUCTURED SETTLEMENT/ANNUITY QUOTE SHEET

Name________________________________________

Phone____________________________

Fax____________________________

Date___________________________

E-Mail ______________________________

How did you find us ___________________

Name of Insurance Company ___________________

State You live in ________________

State settled in _________________

What type of settlement?

__car accident __personal injury __wrongful death __other, explain ____

Was this work related? Y or N Have you sold payments before? Y or N

Payments?

__monthly __quarterly __annually __ combination

Monthly Payment Amount _________________

Paid on what day of month ________________

When was the first payment _______________

When is the last payment _________________

Do payments increase? Y or N If yes, date and amount of increase _________

Lump sum payments?

Date ______ Amount _______ Date ______ Amount ________

Date ______ Amount _______ Date ______ Amount ________

Date ______ Amount _______ Date ______ Amount ________

Date ______ Amount _______ Date ______ Amount ________

How many payments would you like to sell?

How much money would you like to raise?

Print and mail this sheet to: