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Viatical 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:
Payment Amount:$

 

Death Benefit:

 

IIlness Type:

 

Date of Diagnosis:

 

Insurance Company:

 

Sale Price:$

 

Why are you selling?:

 

How much immediate cash do you need?:$

 

Comments:

 

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. 
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