Structured Settlements DELMarVA Judgment Services

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Structured Settlement Worksheet
*Bold fields are required.*
*Name:*
*Address:*
*City:*
*State:*
*Zip:*
*Work#:*
Fax#:
Cell#:
*Home#:*
*Best time to call:*
*How did you hear of us?:*

*Email:*
*Insurance Co. Making Payments:*
*Payment Amount:$*
*Payment Made:*
*When is/was the starting date?*
*When is/was the ending date?:*
*1st Lump Payment & Date:*
*2nd Lump Payment & Date:*
*3rd Lump Payment & Date:*
*4th Lump Payment & Date:*
*5th Lump Payment & Date:*
*Start date of guaranteed period:*
*End date of guaranteed period:*
*Number of Payments Remaining:*
*Type of Accident:*
*Age of Recipient:*
*Why are you selling?:*
*How much immediate cash do you need?:$*
Check if you have these documents:
Annuity Policy:
Settlement Agreement:
The data, which we collect from you is not an application for credit. The intent of this form is for us to determine if a relationship between DELMarVA Judgment Services and/or its assigns and you and/or your company would be mutually beneficial. By submitting the required form, you authorize DELMarVA Judgment Services and/or its assigns to access any credit reporting agencies for which we are a member in your security interest under any agreements and transactions relating to DELMarVA Judgment Services and you and/or your firm. Your information is held in the strictest confidence and is used to help you achieve your goals in an expeditious and professional manner. ____________________________________________________________________________