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

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