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Name
Date
Phone
Email
Name of Insurance Company paying the settlement?
State you live in?
What type of settlement?
Car Accident
Personal Injury
Wrongful Death
Other
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
Do you receive lump sum payments? If so, 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?
Submit