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 =

Settlement Information Worksheet