*Full Name:	*State: AK AL AR AZ BC CA CO CT DC DE FL GA GU HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VI VT WA WI WV WY *Zip:
Company:	Telephone:
*Address:	Fax:
*City:	*Defendant/Insurer:

Claimant Information

Full Name:	Sex: Male Female
DOB/Age:

Case Information

Type of Claim	Physical Injury? Yes No
	Workers Comp? Yes No
Describe Incident	Current Condition

Financial Information

Proposed Settlement Amount	Attorney Fees
Specials	Amount for Annuity
Up Front Cash

Structured Settlement Plan

Any thoughts on benefit payments? (i.e. life with x years guaranteed, college lump sums, etc.)

Additional Notes

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