Structured Settlement or Annuity

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Name______________________________

Phone _____________________________

Fax _______________________________

E-mail: ____________________________

Date_______________________________

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?


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