First name:  *

Last name:  *

Your time zone:  *

Best time to call you back with a quote:  *

Area code & Phone number:  *

Email address:  *

Address:  *

City:  *

State: Select One:AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington D.C.West VirginiaWisconsinWyoming

Zip code:  *

This annuity is the result of: Personal Injury SettlementWrongful Death SuitProduct LiabilityInvestment AnnuityWorkmans CompensationPensionOther

Briefly describe the circumstances under which this payment stream was created:  *

Is this payment steam the result of a court ordered settlement: NoYes

Is this payment steam the result of an out of court settlement: NoYes

In what state was it settled: Select One:AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington D.C.West VirginiaWisconsinWyoming

Were you a minor at the time of settlement:  *

On the front of the annuity policy who is listed as the Owner of the Policy:  *

Name of insurance company that is sending your check:  *

Payment frequency: MonthlyQuarterlySemi-AnnualAnnualOther

Amount of payment:  *

Due date of next payment (month/day/year):  *

Through what date are your payments guaranteed (month/day/year):  *

Do your payments have an annual adjustment: NoYes

If yes what percent is it:

With what payment does the adjustment occur (month/day/year):

Do you receive lump sum payments: NoYes

If yes please list the date and amount of each lump sum payment due:

Reason for selling your annuity or structured settlement:  *

What type of purchase are you interested in: Full PurchasePartial Purchase

Is there a specific dollar amount you need to raise:  *

Do you have and can you supply copies of the following documents:

Annuity policy: NoYes

Extended Release/Settlement Agreement: NoYes

Copy of most recent check or check stub: NoYes

Copy of front page of most recent tax return: NoYes

Security code:   *

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