Your Name:  * Email Address:  * Area Code & Phone Number:  * Best Time To Call You Back With a Quote:  * Your State of Residence: SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington D.C.West VirginiaWisconsinWyoming This annuity is the result of: Injury SettlementWorkmans CompensationWrongful Death SuitProduct LiabilityPensionDivorce LienInvestment Annuity Other In what state was it settled? SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington D.C.West VirginiaWisconsinWyoming Were you a minor at the time of settlement? NoYes 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: Yes No If yes what percent is it: With what payment does the adjustment occur (month/day/year): Do you receive lump sum payments: YesNo If yes please list the date and amount of each lump sum payment due: 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 What is your relationship to this transaction: Annuitant/SellerNote Broker/Note FinderMortgage Broker/Loan OfficerRealtor/AgentAttorney/CPA/Fin. PlannerEstate RepresentativeFamily/Friend I am ready to recieve a free quote and if your offer meets my approval I will be ready to proceed within the next: 30 days60 days90 days Security code:   * Do not enter anything in this field:

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