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Settlement / Structured Settlement Quote
Full Name
*
Phone
*
Fax
Date
Email
*
How did you find us
Insurance company paying the settlement?
State client lives in
What type of settlement?
Car Accident
Personal Injury
Wrongful Death
Other
Was this work related?
Yes
No
If yes, we cannot do this deal–stop here!
Have you sold payments before?
Yes
No
If yes, to what company?
What payments?
How are payments paid out?
Monthly
Quarterly
Annually
Combination
Monthly payment amount
Paid on what day of the month
Do payments increase?
Yes
No
If yes, date and amount of increase
If client receives lump sum payments, when are they due and how much?
Date
Amount
Date
Amount
Date
Amount
Date
Amount
Date
Amount
Date
Amount
Date
Amount
Date
Amount
How many payments would you like to sell?
How much money would you like to get by selling these payments?
Type the characters you see in the picture below
