Settlement Quote Application

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Structured Settlement Funding Application

Please provide complete and accurate information.
All information will be held strictly confidential.

Contact Information:

Name

Day Phone

Eve. Phone

Best time to call

Fax

Mail Address

City

State

Zip

Payment Information:

(If other, please explain):

* Sorry, we cannot purchase Worker's comp, Alimony, Retirement
or Pension based payments. Payments need to be made by an Insurance Company.

I receive:

payments of

My monthly payments increase:

% annually on of each year.

Date first payment received:

Date of final payment:

Periodic Lump Sum Payments Due:

Dates:

Amounts:

Name of the company or agency making payments to you:

Are you currently employed?

How do you support yourself?

Were you a minor at time of settlement?

How long are your payments guaranteed certain?

My goal is to raise:

Please tell us how receiving a lump sum now will help you:

Additional Comments:

Please include any information you think might be helpful:

Marketing Info:

Please tell us how you found us:
If by search list keywords used:
If other please explain: