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Agent Name
*
Date
*
MM slash DD slash YYYY
Phone
*
Email
*
Name of Insurance Company paying the settlement?
*
State client lives in?
*
What type of settlement?
*
Car Accident
Personal Injury
Wrongful Death
Was this work related?
*
Yes
No
Have you sold payments before?
*
Yes
No
How are payments paid out?
*
Monthly
Quarterly
Annually
Combination
Monthly Payment Amount
*
Paid on what day of month
*
Do payments increase?
*
Yes
No
Date and Amount of Increase
*
If client receives lump sum payments, when are they due and how much?
Date
Amount
Date
Amount
Date
Amount
Date
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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