Broker Price Request

Annuity Transfers will provide an immediate price TO YOU for any structured settlement payment stream. We will eventually discuss with you the ultimate price TO THE SELLER over the phone or via email. Please provide the following information regarding the payment stream that your client wishes to sell: Required fields are denoted with a

Broker Contact:
Broker Firm:
Broker Phone:
Broker Email:

Seller's First Name
Seller's Middle Name
Seller's Last Name
Seller's Address:
Seller's City:
Seller's State:
Seller's Zip:
Name of the insurance company making payments:

Monthly Payments? Yes No

Are your payments associated with worker's compensation? Yes No

Monthly payment amount is:

The monthly payments to be purchased
start and end (mm/dd/yyyy)

Does the monthly payment stream increase annually? Yes No

If so, what is the percentage increase?

Do you receive annual or other lump sum payments? Yes No

Please list the date and amount of each payment
Date			Amount
Date			Amount
Date			Amount
Date			Amount
Date			Amount
Date			Amount

Comments: