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Structured Settlement Quotation Form

Beneficiary's Name
Your Email Address
Contact Phone Contact Fax

Settlement Information Worksheet

Name of Insurer paying you
Type of Payment being received Pre-Settlement     Structured Settlement   Investment Annuity
Current Payment Amount    
This Payment is being received  Monthly    Quarterly     Annually  
Total Award Amount (if known) Date of your 1st Payment
Is this a "Life" Payment   Yes       No      
If not a "Life" Payment, what is the Final Payment Date?  
Type of Accident (why you are receiving payments)
Are you seeking... Total Cash Out    Partial Cash Out
Why are you seeking these funds?  What are your current needs?
Please answer the math question.   The sum of 9 + 3 =