Settlement Questionnaire Form

SETTLEMENT / ANNUITY QUESTIONNAIRE FORM

* Indicates required field

Full Name (as per contract) *

First

Last

Email *

Phone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Type of Settlement / Annuity: (i.e. Auto Accident, Pension Military/Civil , Personal Injury, Worker Comp, Inheritance, etc.) *

Is this derived from a Workmans Compensation Claim: Yes/No *

What State Settled In: *

State of Residency at that time: *

Date Settlement was created: *

Settled In or Out of Court: *

Settlement/Auunitants Age at time: *

Date Of Birth: *

Settlement/Annuity Maker: *

Does this Settlement/Annuity Allow for Assignment: Yes/No *

Settlement/Annuity Payor: *

Annuity check Issuer: *

City & State of Insurance Co: *

Gross Payment $ Amount: *

Tax Withholdings from Payments: *

Other Withholdings from Payments: *

Net Payment $ Amount: *

Is there any Cost of Living Adjustments to the Payments: *

Guaranteed Payments: *

Date of First Payment: *

How many Payments Remain: *

Terms of Settlement/Annuity: *

Lump Sums: *

Monthly Payments: *

Sell Full or Partial Payments: *

Schedule of Payments: *

Your Credit Situation: *

Details - If any Bankruptcy *

Other Income Support: *

Additional Comments: (more the better) *

Enter Validation Code (required): 345Q *

Submit

settlement_questionnaire.pdf
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settlement_questionnaire.doc
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