Enter today's date: -- mm/dd/yy

How did you hear about Westshore?  Radio Television Newspaper Mail Referral Other

Please specify source: 

Please provide the following contact information:

Name
Title
Organization
Street Address
City
State/Province
Zip/Postal Code
Work Phone
Home Phone
FAX
E-mail

The annuity is a result of? (auto accident, slip and fall, etc.)  *workers compensation not eligible   

 

Were you a minor (under 18) when the case was settled? Yes No

Enter the name of the state in which you lived when the settlement occurred.

Exact Name of Annuity Owner (get from policy - usually an insurance company)

Exact Name of Annuity Issuer (insurance company that sends payments to you)

Please specify exact terms of payment stream (exact dates, payment amounts, monthly, quarterly annually, semi annually every five years, etc)

How do you receive your payments?    Check by mail Direct deposit into checking Direct deposit into savings Attorney Other

Is the annuity your only source of income?    Yes No

How much money do you need?    $

The money will be used for what purpose?

Enter the date of you will need to receive your money:    

-- mm/dd/yy

Please rate your level of interest in selling the subject Annuity Payments:  Very Interested Would like to sell now Somewhat Interested May Sell Soon Just Curious

Please indicate which items you have in your possession:

The fully executed Settlement Agreement
The complete Annuity Policy
The Qualified Assignment
The Court Order Approving Settlement for Minor (if
      you were a minor when settled)

Please add any pertinent information that you may want to have considered: