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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 =