First Name:
Last Name:
Address:
City: State:
ZIP:
Phone:
Fax: SSN:
Credit Worthiness (type: Excellent, or Good,
or Fair, or Bad):
Provide information on any existing Judgments,
Child Support or Tax Liens, if applicable:
Provide information on Structured Settlement,
Annuity Based Workers Compensation, or Annuity Based Disabilities:
Explain any reason why you may be uninsurable:
Type "Yes", if Smoker:
Insurance Company paying:
Dates and Amounts of Payments
Date
Amount
Date
Amount
Number of Payments for Sale:
Provide information on your primary objectives
of this sale:
