Please use this quote form for Annuities, Structured Settlements and Lottery Winnings.

If you are interested in selling a mortgage note or a life insurance policy (viatical settlement), please click on the links below:

Viatical Settlements
 

Quote Form

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Your Contact Information:

Your Email Address

Your Name

Street Address

City

State

Day Time Phone

Evenings

Zip Code

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What type of structured settlement are you currently receiving payments from?

 Lottery Winnings

 Annuity

 Insurance-Settlement

 Wrongful Death

 Auto Accident

 Medical Malpractice

 Other

Please Specify

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Specific Payment Information

Name of the company making payments to you:

Payments are made in the amount of:

Frequency:

If other, please specify:

Date first payment received:

Date of final payment:

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If you are receiving lump sum payments, please complete this section.

Dates

Amounts

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Please let us know of any additional information or comments:

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You have the option to print this form and send or fax it to:

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Phone: 1-888-732-3942              Fax: 336-299-9932
 

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