Structured Settlement
Quote Request


For a quote on selling your Structured Settlement, please fill out the form below and we will respond promptly.

Recipient(s) Name: 
Home Phone:    Work Phone: 
Fax:    E-mail: 
City:    State:     Zip: 
Best Time and Place to Contact You: 
Type of Payments You Receive:  
Reason for Receiving Benefits:   
State Claim was Settled in: 
Name of Policy Payor (insurance co.): 
Name of Policy Issuer (if different): 
How Often Do You Receive Installments?
Installment Amount:  $
Next Installment Due Date: 
Number of Guaranteed Payments Remaining:
How Much Is the Annual % of Increase in Your Payments? (if applicable)
Date of Annual Increase Each Year (if applicable)
Do You Have Other Sources of Income? 
Do You Have a Copy of the Annuity Policy or Benefit Letter? 
Do You Have a Copy of the Executed Release & Settlement Agreement? 
Have You Previously Requested a Quote From Another Company? 

When and how much are your lump payments: (if applicable) 

Due Date:  Amount:$

Due Date:  Amount:$

Due Date:  Amount:$

Due Date:  Amount:$

Due Date:  Amount:$

Due Date:  Amount:$


If you have any comments please state them in the box below. 

Note:  For large or long term settlements, please specify the amount of cash you need.  We will offer to purchase only the portion of your settlement that will allow us to meet your financial needs.  Without specifying the amount needed, we will give a quote on all payments or on the largest number of payments that we are able to purchase.

How did you find us?

Referred By: (for Affiliate or Broker use)







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