Lottery Quote

Broker Name:				Phone:

Fax:				Date:

Email:

How did you find us:


What type of prize winning was it?
	State Lottery
	IGT Casino Winning
	Other	Specify:

Have you sold payments before?			Yes
			No

If yes, to what company?

What was the win date:

Were you the only winner?			Yes	If no, how many other winners:
			No	What % did you win?

What was the gross amount won:				What is the net annual payment?

What state was the prize won in?				What state do you reside in?

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