Settlement Quote

Broker Name:					Phone:

Fax:					Date:

Email:

How did you find us:


Name of insurance company paying the settlement?

State client lives in:

What type of settlement?
	Car Accident
	Personal Injury
Wrongful Death
	Other	Explain:

Was this work related?
Yes		No
If yes, we cannot do this deal–stop here!

Have you sold payments before?				Yes
				No

If yes, to what company?

What payments?

How are payments paid out?
	Monthly
	Quarterly
	Annually
	Combination

Monthly payment amount:					Paid on what day of the month:

Do payments increase?			Yes		If yes, date and amount of increase:
			No

If client receives lump sum payments, when are they due and how much?
Date:					Date:
Amount:					Amount:

Date:					Date:
Amount:					Amount:

Date:					Date:
Amount:					Amount:

Date:					Date:
Amount:					Amount:

How many payments would you like to sell?

How much money would you like to get by selling these payments?

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