Settlement

    First Name

    Last Name

    Address

    City

    State

    Zip

    Phone Number

    Email Address

    How did you find us?

    If Other, please specify

    Reason For Settlement

    Date of Settlement

    Date of First Check

    Original Amount Due

    Current Amount Due

    Pay Schedule

    Amount of Most Recent Check

    Original Guarantee Term:  

    Lump 1 ($):

    Date:

    Lump 2 ($):

    Date:

    Lump 3 ($):

    Date:

    Lump 4 ($):

    Date:

    Lump 5 ($):

    Date:

    Lump 6 ($):

    Date:

    Other Notes and Terms

    Owner of Policy

    Company who Pays

    How much do you want to assign?

    Has this settlement been previously assigned?

    Is this settlement currently assigned?

    If so, to whom?

    Guaranteed or Life Contingent?