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Structured Settlement Quotation Form
Beneficiary's Name
*
First
Last
Your Email Address
*
Contact Phone
*
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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?
*
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