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| Recipient(s) Name:
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| Telephone: Home Work |
| Fax:
E-mail: |
| Address: |
| City: State: Zip: |
| Time and Place to Contact You: |
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| Type of Payments You Receive |
| Reason for Receiving Benefits |
| Name of Policy Payor (insurance co.):
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| Name of Policy Issuer (if different): |
| How Often Do You Receive Installments? |
| Installment Amount: $ |
| Next Installment Due Date: |
| Number of Guaranteed Payments Remaining:
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| How Much Is the Annual % of Increase in Your
Payments? (if applicable) |
| Date of Annual Increace Each Year (if
applicable) |
| 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 Received a Quote From Another Company?
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| 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:$
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| If you have any comments please state them in the box below. (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.) |
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| How did you find us? |
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Referred By: (for Affiliate or
Broker use)
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