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Quote Request

*Full Name:
*State:
*Zip:
Company:
Telephone:
*Address:
Fax:
*City:
*Defendant/Insurer:

Claimant Information

Full Name:
Sex:
DOB/Age:

Case Information

Type of Claim
Physical Injury?
Workers Comp?
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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