ANNUITIES STRUCTURED SETTLEMENTS QUOTE

Name:Address:

City:       State: Zip:

County of Residence:        Marital Status: 

Day Phone:  ()          Evening Phone: ()

FAX Phone:  ()         Work Phone:    ()

Best time to call: A.M.    P.M.    Eastern    Pacific    Central

E-mail address:    Social Security No.:

Dateof Birth: (Mo/date/Yr)      Are you employed:    Yes    No

Occupation:        Employer Name:

If not employed, How do you support yourself?

SETTLEMENT INFORMATION

What kind of payments are your receiving?

How did you get your Income Stream?

       Is this Workers Comp Related?    

Were you a minor when you acquired this?    Yes      No

Number of payments you receive: Amount of Payments:

If other (explain)

The next payment is due on: (Mo/Day/Yr)

Annuity Provider:  Insurance Co. Name:

                                      Agency Name:

                                   Company Name:

Jurisdiction:  Circuit Court    Superior Court   Court Docket #: 

Start date: (Mo/Day/Yr)         End date: (Mo/Day/Yr 

Plaintiff Attorney Name:   

Plaintiff Attorney Law Firm Name:

Plaintiff Attorney Mailing Address:

City:       State: Zip:

Plaintiff Attorney Phone:   FAX:

Do you have lump sum payments?      Yes       No

If yes list the date and amount of each lump sum payment:

                      Date                                                         Amount

           $

           $

           $

           $

           $

           $

How long are these payments guaranteed?

How many payment have you received so far?

How many payments are left?

Why do you wish to sell?

How much do you need to raise?

Do you want to sell the whole income stream   partial payments.

If partial:  I want to sell payments.

Have you ever used a cash flow broker before?    Yes     No

Have you been shopping this deal?  If  yes, what is the highest bid you received?

Who gave this bid to you?

This will help with our marketing.

Search Engine------------Name of search engine:        

Keywords Used--------------

Banner Ad----Where did you see our banner?

Classified Ad---------Where did you see it? 

Newsgroup--------------Which newsgroup?

Other: -----