Structured Settlement Form

Name of Client:  ________________________________________________________________________________________________

Date of Loss:   _________________________________________________________________________________________________

Date of Birth:  __________________________________________________________________________________________________

Date Annuity Begins:   ___________________________________________________________________________________________ 

Amount Per Month:  _____________________________________________________________________________________________

¨  Life Only			  ¨  Life & Years Certain		   _____  Number of Years

Balloon Payments:	¨  yes   	¨  no

In What Years: _________________________________________________________________________________________________	
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What Amounts:	________________________________________________________________________________________________
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Has your clients life expectancy dropped due to accident, if so explain.
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