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1 .
First Name *
2 .
Last Name *
3 .
Email Address *
4 .
Telephone Number
5 .
Are you personally receiving payments on this note? *
Yes No
6 .
What is the name of the insurance company paying the settlement? *
7 .
What state does the recipient live in? *
8 .
What state was the case settled in? *
9 .
What type of settlement was involved? (If the settlement was work related, we cannot buy it. We're sorry) *
Car Accident
Personal Injury
Wrongful Death
Disability
Other
10 .
If other, please describe:
11 .
Have you sold payments from this settlement before? *
Yes No
12 .
What is the age of the recipient? *
13 .
How are the payments paid out? *
Monthly
Quarterly
Annually
Other
14 .
If other, please describe:
15 .
What is the monthly/quarterly/annual payment amount? *
16 .
On what day(s) of the month/quarter/year is the payment due? *
17 .
Do the payments increase? *
Yes No
18 .
If yes, please give the amount and date of each increase.
19 .
If recipient receives lump sum payments, please list when they are due and how much?
20 .
Date and Amount
21 .
Date and Amount
22 .
Date and Amount
23 .
Date and Amount
24 .
Date and Amount
25 .
Date and Amount
26 .
Date and Amount
27 .
Date and Amount
28 .
How many payments would you like to sell? *
29 .
How much money would you like to get by selling these payments? *
30 .
Is this structured settlement the recipients only form of income? *
Yes No
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